| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,755 |
3,755 |
$132K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,377 |
846 |
$100K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
833 |
622 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
3,149 |
3,149 |
$79K |
| D1351 |
Sealant - per tooth |
1,694 |
528 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,954 |
1,954 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
972 |
916 |
$36K |
| D0240 |
|
1,963 |
1,336 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,251 |
2,251 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,193 |
1,193 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,758 |
1,757 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
204 |
141 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
434 |
294 |
$25K |
| D1110 |
Prophylaxis - adult |
434 |
434 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
189 |
118 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,091 |
1,089 |
$11K |
| D0274 |
Bitewings - four radiographic images |
386 |
386 |
$9K |
| D0330 |
Panoramic radiographic image |
227 |
227 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
261 |
260 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
642 |
634 |
$4K |
| D9110 |
|
46 |
45 |
$1K |
| D9248 |
|
12 |
12 |
$1K |
| D4910 |
|
16 |
16 |
$826.50 |