| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,144 |
2,021 |
$94K |
| D1206 |
Topical application of fluoride varnish |
2,121 |
2,010 |
$83K |
| D1351 |
Sealant - per tooth |
4,425 |
905 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,430 |
537 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,714 |
1,619 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,205 |
1,137 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
641 |
336 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,299 |
2,013 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
917 |
864 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,181 |
856 |
$15K |
| D1353 |
|
1,065 |
272 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
272 |
146 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
727 |
319 |
$14K |
| D0330 |
Panoramic radiographic image |
296 |
280 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,025 |
959 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
156 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
38 |
$3K |
| D0272 |
Bitewings - two radiographic images |
182 |
167 |
$3K |
| D7111 |
|
80 |
42 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
52 |
28 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$707.28 |