| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,503 |
3,501 |
$107K |
| D1351 |
Sealant - per tooth |
1,921 |
530 |
$60K |
| D1206 |
Topical application of fluoride varnish |
2,404 |
2,399 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,200 |
2,200 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
729 |
418 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
461 |
209 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
394 |
242 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,232 |
1,232 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,984 |
1,982 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,245 |
2,239 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,552 |
2,548 |
$13K |
| D2335 |
|
141 |
50 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,185 |
1,185 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
167 |
62 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
165 |
$8K |
| D1110 |
Prophylaxis - adult |
182 |
182 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
199 |
187 |
$7K |
| D0274 |
Bitewings - four radiographic images |
224 |
224 |
$5K |
| D0330 |
Panoramic radiographic image |
127 |
126 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
149 |
149 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
314 |
311 |
$3K |
| D9920 |
|
17 |
17 |
$385.70 |