| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,943 |
4,943 |
$155K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,259 |
1,027 |
$117K |
| D1206 |
Topical application of fluoride varnish |
5,021 |
4,922 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
3,711 |
3,711 |
$80K |
| D1351 |
Sealant - per tooth |
2,051 |
715 |
$65K |
| D1354 |
|
4,146 |
864 |
$62K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
788 |
482 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,298 |
661 |
$44K |
| D0272 |
Bitewings - two radiographic images |
3,398 |
3,398 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,231 |
694 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,393 |
1,393 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
445 |
292 |
$24K |
| D0240 |
|
1,011 |
1,011 |
$23K |
| D1110 |
Prophylaxis - adult |
398 |
398 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
144 |
108 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
362 |
362 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
677 |
677 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
677 |
676 |
$7K |
| D0274 |
Bitewings - four radiographic images |
126 |
126 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
66 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
154 |
$2K |
| D9110 |
|
52 |
52 |
$928.72 |
| D9310 |
|
12 |
12 |
$643.08 |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$307.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
55 |
$285.94 |