| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,791 |
5,790 |
$258K |
| D1206 |
Topical application of fluoride varnish |
5,851 |
5,850 |
$182K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,288 |
1,347 |
$158K |
| D1351 |
Sealant - per tooth |
7,302 |
2,054 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
4,842 |
4,842 |
$121K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,100 |
755 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,399 |
2,319 |
$60K |
| D0603 |
|
3,658 |
3,656 |
$35K |
| D0272 |
Bitewings - two radiographic images |
3,175 |
3,169 |
$31K |
| D1353 |
|
2,882 |
741 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
592 |
387 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
5,236 |
5,222 |
$26K |
| D9920 |
|
734 |
713 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,828 |
4,822 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
284 |
282 |
$13K |
| D0274 |
Bitewings - four radiographic images |
698 |
698 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
28 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
219 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
154 |
154 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |