| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,139 |
10,154 |
$296K |
| D1351 |
Sealant - per tooth |
12,233 |
1,827 |
$281K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,865 |
1,403 |
$278K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,107 |
1,538 |
$273K |
| D0120 |
Periodic oral evaluation - established patient |
8,065 |
6,762 |
$198K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,308 |
10,275 |
$173K |
| D0274 |
Bitewings - four radiographic images |
7,224 |
5,547 |
$164K |
| D0330 |
Panoramic radiographic image |
3,424 |
2,728 |
$149K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,500 |
3,693 |
$119K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
795 |
131 |
$81K |
| D0140 |
Limited oral evaluation - problem focused |
498 |
319 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
201 |
26 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
890 |
646 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
326 |
276 |
$8K |
| D0272 |
Bitewings - two radiographic images |
501 |
363 |
$7K |
| D1110 |
Prophylaxis - adult |
148 |
136 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
16 |
$3K |
| D2330 |
|
15 |
12 |
$1K |