| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,802 |
6,802 |
$195K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,888 |
1,372 |
$168K |
| D1351 |
Sealant - per tooth |
4,766 |
1,499 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
5,362 |
5,362 |
$108K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
924 |
671 |
$105K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,811 |
1,346 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,792 |
2,792 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,107 |
5,107 |
$73K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,746 |
2,537 |
$71K |
| D0330 |
Panoramic radiographic image |
1,514 |
1,514 |
$70K |
| D1110 |
Prophylaxis - adult |
1,367 |
1,367 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
3,566 |
3,525 |
$51K |
| D0272 |
Bitewings - two radiographic images |
2,667 |
2,667 |
$46K |
| D1206 |
Topical application of fluoride varnish |
3,028 |
3,028 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
475 |
379 |
$30K |
| D0274 |
Bitewings - four radiographic images |
962 |
962 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,914 |
2,863 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
718 |
704 |
$21K |
| D7111 |
|
103 |
83 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
46 |
37 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D2330 |
|
19 |
12 |
$1K |