| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,750 |
4,539 |
$183K |
| D1206 |
Topical application of fluoride varnish |
6,670 |
6,344 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
5,824 |
5,542 |
$151K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,050 |
424 |
$134K |
| D1351 |
Sealant - per tooth |
3,944 |
886 |
$119K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,093 |
539 |
$92K |
| D1110 |
Prophylaxis - adult |
1,902 |
1,810 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
874 |
570 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,135 |
1,076 |
$65K |
| D0272 |
Bitewings - two radiographic images |
3,758 |
3,593 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
889 |
623 |
$58K |
| D9248 |
|
175 |
174 |
$42K |
| D1330 |
|
3,909 |
3,903 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,376 |
1,295 |
$34K |
| D0240 |
|
1,517 |
919 |
$26K |
| D0330 |
Panoramic radiographic image |
558 |
542 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
758 |
721 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
256 |
135 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,503 |
1,429 |
$15K |
| D0603 |
|
1,538 |
1,537 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,259 |
1,034 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
122 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
202 |
187 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
278 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$715.31 |
| D0602 |
|
59 |
59 |
$590.00 |