| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,504 |
4,494 |
$195K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,485 |
1,294 |
$167K |
| D1206 |
Topical application of fluoride varnish |
4,607 |
4,594 |
$142K |
| D1351 |
Sealant - per tooth |
7,264 |
1,718 |
$136K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,005 |
472 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
3,741 |
3,733 |
$92K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,255 |
2,183 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
677 |
418 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
757 |
516 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,438 |
2,434 |
$23K |
| D1353 |
|
2,572 |
649 |
$23K |
| D0603 |
|
2,664 |
2,648 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
4,171 |
4,154 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
235 |
153 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
161 |
130 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,972 |
3,958 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
482 |
481 |
$11K |
| D0274 |
Bitewings - four radiographic images |
817 |
813 |
$10K |
| D9920 |
|
320 |
302 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
120 |
$5K |
| D2932 |
|
35 |
12 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
54 |
54 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$1K |
| D0601 |
|
121 |
120 |
$930.00 |