| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,637 |
6,584 |
$293K |
| D1206 |
Topical application of fluoride varnish |
6,655 |
6,601 |
$205K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,932 |
1,518 |
$205K |
| D1351 |
Sealant - per tooth |
8,644 |
2,374 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
5,833 |
5,783 |
$144K |
| D9999 |
Unspecified adjunctive procedure, by report |
306 |
297 |
$122K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,932 |
1,150 |
$106K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,577 |
2,552 |
$64K |
| D9248 |
|
342 |
333 |
$43K |
| D0272 |
Bitewings - two radiographic images |
3,913 |
3,878 |
$39K |
| D1353 |
|
3,889 |
957 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
336 |
184 |
$34K |
| D0603 |
|
3,364 |
3,328 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
5,349 |
5,294 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
481 |
303 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
345 |
188 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,916 |
4,865 |
$16K |
| D9920 |
|
552 |
550 |
$14K |
| D0274 |
Bitewings - four radiographic images |
925 |
925 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
232 |
232 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
354 |
354 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
99 |
76 |
$8K |
| D0601 |
|
819 |
819 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
265 |
$7K |
| D2332 |
|
29 |
16 |
$2K |
| D7111 |
|
31 |
25 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$600.00 |
| D0602 |
|
50 |
50 |
$500.00 |