| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,237 |
12,038 |
$523K |
| D1206 |
Topical application of fluoride varnish |
17,217 |
16,642 |
$397K |
| D0120 |
Periodic oral evaluation - established patient |
9,504 |
9,414 |
$291K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,904 |
1,117 |
$271K |
| D0330 |
Panoramic radiographic image |
2,936 |
2,898 |
$208K |
| D1351 |
Sealant - per tooth |
5,641 |
1,527 |
$180K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,815 |
2,736 |
$159K |
| D1354 |
|
8,668 |
1,966 |
$149K |
| D1110 |
Prophylaxis - adult |
2,003 |
1,985 |
$119K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
739 |
134 |
$118K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,970 |
1,905 |
$115K |
| D0272 |
Bitewings - two radiographic images |
3,006 |
2,949 |
$85K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,140 |
1,120 |
$51K |
| D0240 |
|
1,815 |
1,296 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
796 |
782 |
$35K |
| D1330 |
|
1,380 |
1,357 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
316 |
214 |
$31K |
| D9420 |
|
127 |
115 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
229 |
84 |
$22K |
| D3240 |
|
101 |
40 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
369 |
353 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
63 |
24 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
388 |
122 |
$5K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$663.00 |