| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,385 |
8,161 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,760 |
693 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
9,432 |
9,199 |
$66K |
| D1206 |
Topical application of fluoride varnish |
10,183 |
9,895 |
$53K |
| D1351 |
Sealant - per tooth |
3,891 |
940 |
$36K |
| D0272 |
Bitewings - two radiographic images |
6,065 |
5,902 |
$34K |
| D0240 |
|
4,027 |
3,498 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
488 |
192 |
$27K |
| D1110 |
Prophylaxis - adult |
2,331 |
2,277 |
$26K |
| D0274 |
Bitewings - four radiographic images |
4,057 |
3,926 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
721 |
401 |
$24K |
| D0330 |
Panoramic radiographic image |
1,484 |
1,425 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
7,676 |
7,364 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,718 |
6,942 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,290 |
1,255 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
465 |
225 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,387 |
1,242 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
499 |
458 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
451 |
443 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
558 |
546 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
27 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
106 |
37 |
$3K |
| D9248 |
|
142 |
116 |
$3K |
| D1354 |
|
674 |
103 |
$3K |
| D2332 |
|
23 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
525 |
503 |
$250.00 |