| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,704 |
5,704 |
$257K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,884 |
1,497 |
$202K |
| D1206 |
Topical application of fluoride varnish |
5,968 |
5,968 |
$186K |
| D1351 |
Sealant - per tooth |
8,270 |
2,273 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
4,921 |
4,921 |
$123K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,778 |
1,075 |
$98K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,616 |
2,573 |
$65K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
488 |
328 |
$49K |
| D1353 |
|
4,489 |
1,070 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
837 |
546 |
$42K |
| D0272 |
Bitewings - two radiographic images |
3,430 |
3,430 |
$34K |
| D0603 |
|
2,720 |
2,720 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
387 |
258 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
4,317 |
4,313 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
444 |
442 |
$20K |
| D9920 |
|
586 |
581 |
$15K |
| D7111 |
|
325 |
210 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,876 |
3,876 |
$13K |
| D0601 |
|
1,190 |
1,190 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
451 |
451 |
$11K |
| D0274 |
Bitewings - four radiographic images |
904 |
904 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
411 |
411 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
40 |
$4K |
| D0602 |
|
327 |
327 |
$3K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |