| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,100 |
10,094 |
$446K |
| D1206 |
Topical application of fluoride varnish |
10,347 |
10,338 |
$321K |
| D1351 |
Sealant - per tooth |
13,955 |
3,600 |
$274K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,626 |
2,209 |
$250K |
| D0120 |
Periodic oral evaluation - established patient |
9,289 |
9,285 |
$231K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,195 |
4,065 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,727 |
1,193 |
$94K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,684 |
970 |
$91K |
| D1353 |
|
8,669 |
2,094 |
$81K |
| D9999 |
Unspecified adjunctive procedure, by report |
176 |
171 |
$70K |
| D0272 |
Bitewings - two radiographic images |
6,200 |
6,195 |
$61K |
| D0603 |
|
5,802 |
5,798 |
$55K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
537 |
295 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
9,789 |
9,772 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,271 |
9,258 |
$29K |
| D9248 |
|
228 |
223 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
369 |
215 |
$24K |
| D0274 |
Bitewings - four radiographic images |
2,019 |
2,014 |
$24K |
| D9920 |
|
754 |
749 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
279 |
277 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
278 |
277 |
$7K |
| D1110 |
Prophylaxis - adult |
155 |
155 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$3K |
| D0601 |
|
166 |
166 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
15 |
$1K |
| D7111 |
|
19 |
12 |
$855.00 |
| D0602 |
|
69 |
69 |
$680.00 |