| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
24,328 |
24,328 |
$854K |
| D0120 |
Periodic oral evaluation - established patient |
23,681 |
23,681 |
$561K |
| D1206 |
Topical application of fluoride varnish |
28,998 |
28,998 |
$478K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,590 |
2,281 |
$378K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,544 |
1,210 |
$329K |
| D1110 |
Prophylaxis - adult |
5,073 |
5,073 |
$258K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,405 |
1,431 |
$237K |
| D0272 |
Bitewings - two radiographic images |
12,401 |
12,401 |
$237K |
| D1351 |
Sealant - per tooth |
6,857 |
1,931 |
$207K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,932 |
5,762 |
$194K |
| D0330 |
Panoramic radiographic image |
3,222 |
3,222 |
$165K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,410 |
3,410 |
$152K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,354 |
955 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,260 |
2,260 |
$92K |
| D0140 |
Limited oral evaluation - problem focused |
1,874 |
1,862 |
$73K |
| D0220 |
Intraoral - periapical first radiographic image |
4,776 |
4,746 |
$62K |
| D9248 |
|
550 |
547 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,540 |
2,120 |
$27K |
| D9420 |
|
165 |
165 |
$14K |
| D2330 |
|
98 |
78 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
55 |
27 |
$5K |
| D0240 |
|
179 |
154 |
$3K |
| D0274 |
Bitewings - four radiographic images |
95 |
95 |
$3K |