| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,599 |
3,527 |
$158K |
| D1206 |
Topical application of fluoride varnish |
3,758 |
3,684 |
$129K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,131 |
2,103 |
$68K |
| D1351 |
Sealant - per tooth |
3,255 |
490 |
$60K |
| D0240 |
|
4,394 |
2,225 |
$60K |
| D0274 |
Bitewings - four radiographic images |
2,316 |
2,277 |
$53K |
| D0350 |
|
2,666 |
1,619 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
976 |
359 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,349 |
1,308 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
710 |
313 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
595 |
262 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,064 |
1,015 |
$13K |
| D0603 |
|
2,597 |
2,577 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
274 |
125 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
685 |
587 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
262 |
37 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,156 |
1,006 |
$6K |
| D0272 |
Bitewings - two radiographic images |
384 |
355 |
$6K |
| D1110 |
Prophylaxis - adult |
128 |
125 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
153 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
201 |
41 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
179 |
178 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
73 |
$3K |
| D9420 |
|
158 |
62 |
$3K |
| D1999 |
|
18 |
18 |
$270.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
18 |
18 |
$180.00 |