| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,556 |
7,556 |
$265K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,925 |
1,334 |
$200K |
| D1206 |
Topical application of fluoride varnish |
9,665 |
9,665 |
$160K |
| D0120 |
Periodic oral evaluation - established patient |
6,348 |
6,348 |
$149K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,263 |
4,051 |
$138K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,499 |
1,004 |
$125K |
| D1110 |
Prophylaxis - adult |
1,879 |
1,879 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,070 |
2,070 |
$88K |
| D0272 |
Bitewings - two radiographic images |
4,224 |
4,224 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
5,731 |
5,710 |
$75K |
| D1351 |
Sealant - per tooth |
2,008 |
631 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,497 |
1,497 |
$42K |
| D0330 |
Panoramic radiographic image |
807 |
807 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
283 |
236 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
855 |
855 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,180 |
3,130 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
361 |
293 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
304 |
300 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
45 |
38 |
$4K |
| D0160 |
|
30 |
30 |
$3K |
| D2330 |
|
29 |
24 |
$2K |