| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,485 |
2,482 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,027 |
385 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,678 |
1,678 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
279 |
125 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,128 |
1,126 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
876 |
872 |
$23K |
| D1351 |
Sealant - per tooth |
654 |
194 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
537 |
527 |
$22K |
| D1206 |
Topical application of fluoride varnish |
769 |
769 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
429 |
226 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,525 |
1,524 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
699 |
695 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,259 |
1,249 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
123 |
64 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
91 |
$8K |
| D0272 |
Bitewings - two radiographic images |
402 |
401 |
$7K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$5K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$324.00 |