| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,496 |
7,494 |
$308K |
| D0120 |
Periodic oral evaluation - established patient |
6,962 |
6,959 |
$170K |
| D1351 |
Sealant - per tooth |
3,090 |
994 |
$104K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
974 |
603 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,572 |
999 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,988 |
5,986 |
$82K |
| D0272 |
Bitewings - two radiographic images |
5,900 |
5,892 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,512 |
814 |
$68K |
| D1206 |
Topical application of fluoride varnish |
3,291 |
3,286 |
$67K |
| D1110 |
Prophylaxis - adult |
1,225 |
1,225 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,126 |
728 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,460 |
1,460 |
$42K |
| D0330 |
Panoramic radiographic image |
951 |
950 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,685 |
2,674 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,424 |
1,325 |
$13K |
| D0274 |
Bitewings - four radiographic images |
554 |
554 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,612 |
1,610 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
50 |
38 |
$4K |
| D0240 |
|
175 |
168 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
94 |
94 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
163 |
$2K |
| D1999 |
|
25 |
25 |
$600.00 |
| D9310 |
|
13 |
13 |
$596.62 |
| D3120 |
|
131 |
87 |
$0.00 |
| D1330 |
|
74 |
74 |
$0.00 |