| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,222 |
12,188 |
$532K |
| D1351 |
Sealant - per tooth |
22,773 |
5,553 |
$437K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,132 |
3,128 |
$419K |
| D1206 |
Topical application of fluoride varnish |
12,900 |
12,863 |
$398K |
| D0120 |
Periodic oral evaluation - established patient |
11,549 |
11,521 |
$285K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,312 |
2,469 |
$230K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,519 |
744 |
$151K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,418 |
5,359 |
$134K |
| D1353 |
|
12,259 |
2,895 |
$109K |
| D0272 |
Bitewings - two radiographic images |
6,047 |
6,032 |
$59K |
| D7111 |
|
1,080 |
663 |
$48K |
| D0603 |
|
5,754 |
5,724 |
$43K |
| D1110 |
Prophylaxis - adult |
1,038 |
1,033 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
9,148 |
9,119 |
$42K |
| D0274 |
Bitewings - four radiographic images |
3,126 |
3,118 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
742 |
742 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
366 |
287 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,184 |
8,153 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
990 |
989 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
400 |
281 |
$23K |
| D0601 |
|
1,962 |
1,954 |
$16K |
| D9920 |
|
342 |
331 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
188 |
186 |
$8K |
| D0602 |
|
762 |
761 |
$7K |
| D2332 |
|
73 |
54 |
$5K |
| D2330 |
|
57 |
43 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
38 |
24 |
$2K |
| D0270 |
|
13 |
13 |
$65.00 |
| D0350 |
|
12 |
12 |
$60.00 |