| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,376 |
1,376 |
$82K |
| D1110 |
Prophylaxis - adult |
274 |
274 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
546 |
232 |
$24K |
| D1206 |
Topical application of fluoride varnish |
365 |
365 |
$22K |
| D0330 |
Panoramic radiographic image |
188 |
188 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
335 |
185 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
164 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
56 |
$8K |
| D9420 |
|
13 |
13 |
$5K |
| D1351 |
Sealant - per tooth |
1,740 |
338 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
1,472 |
1,472 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
121 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,266 |
1,266 |
$1K |
| D0272 |
Bitewings - two radiographic images |
850 |
848 |
$888.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,217 |
1,196 |
$829.54 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
405 |
398 |
$559.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,142 |
1,085 |
$544.87 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
13 |
$86.00 |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$35.00 |