| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,961 |
4,953 |
$217K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,470 |
1,301 |
$175K |
| D1206 |
Topical application of fluoride varnish |
5,069 |
5,059 |
$157K |
| D1351 |
Sealant - per tooth |
6,395 |
1,745 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
4,532 |
4,523 |
$112K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,353 |
830 |
$74K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
615 |
335 |
$61K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,420 |
2,347 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
983 |
568 |
$57K |
| D1353 |
|
3,305 |
854 |
$30K |
| D0272 |
Bitewings - two radiographic images |
2,524 |
2,519 |
$26K |
| D0603 |
|
2,355 |
2,345 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
3,817 |
3,809 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
173 |
143 |
$14K |
| D9920 |
|
504 |
493 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,543 |
3,538 |
$11K |
| D0274 |
Bitewings - four radiographic images |
866 |
866 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
177 |
177 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
86 |
86 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
36 |
$4K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$2K |
| D0273 |
|
108 |
108 |
$1K |
| D0601 |
|
106 |
106 |
$1K |
| D0602 |
|
65 |
65 |
$600.00 |
| D0350 |
|
12 |
12 |
$65.00 |
| D1310 |
|
47 |
47 |
$0.00 |
| D1330 |
|
48 |
48 |
$0.00 |