| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,125 |
8,125 |
$285K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,393 |
1,392 |
$248K |
| D1206 |
Topical application of fluoride varnish |
10,239 |
10,239 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
6,674 |
6,674 |
$161K |
| D1351 |
Sealant - per tooth |
4,650 |
1,604 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,457 |
890 |
$125K |
| D1110 |
Prophylaxis - adult |
2,170 |
2,170 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,551 |
2,551 |
$104K |
| D0272 |
Bitewings - two radiographic images |
4,825 |
4,825 |
$92K |
| D0330 |
Panoramic radiographic image |
1,606 |
1,603 |
$82K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,276 |
1,276 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,860 |
1,860 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,534 |
1,469 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
221 |
171 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
594 |
589 |
$23K |
| D2330 |
|
196 |
112 |
$16K |
| D7111 |
|
167 |
122 |
$11K |
| D0240 |
|
463 |
250 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
51 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
40 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
426 |
423 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
12 |
$1K |