| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,226 |
13,140 |
$398K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,747 |
798 |
$306K |
| D0120 |
Periodic oral evaluation - established patient |
12,918 |
12,834 |
$271K |
| D1206 |
Topical application of fluoride varnish |
14,537 |
14,441 |
$258K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,746 |
1,423 |
$238K |
| D1351 |
Sealant - per tooth |
9,666 |
2,547 |
$221K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,578 |
1,320 |
$153K |
| D0272 |
Bitewings - two radiographic images |
6,111 |
6,067 |
$117K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,707 |
1,053 |
$111K |
| D1110 |
Prophylaxis - adult |
2,454 |
2,431 |
$100K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,503 |
3,359 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,035 |
2,017 |
$59K |
| D0330 |
Panoramic radiographic image |
1,423 |
1,415 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,821 |
1,808 |
$48K |
| D0240 |
|
2,917 |
2,271 |
$42K |
| D1353 |
|
1,075 |
532 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
578 |
574 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,224 |
1,200 |
$14K |
| D1354 |
|
1,576 |
496 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
65 |
37 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
308 |
221 |
$3K |
| D2332 |
|
43 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$2K |
| D9420 |
|
14 |
14 |
$495.33 |