| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,365 |
3,365 |
$110K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,293 |
617 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,482 |
701 |
$83K |
| D1206 |
Topical application of fluoride varnish |
2,229 |
2,227 |
$51K |
| D1351 |
Sealant - per tooth |
1,381 |
468 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,946 |
2,942 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,650 |
1,650 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,669 |
1,669 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
3,251 |
3,239 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
520 |
292 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
867 |
523 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
776 |
681 |
$23K |
| D0330 |
Panoramic radiographic image |
757 |
757 |
$23K |
| D9310 |
|
333 |
333 |
$16K |
| D0272 |
Bitewings - two radiographic images |
918 |
918 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
953 |
953 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
246 |
246 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
420 |
416 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
40 |
$4K |
| D1510 |
|
42 |
38 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
390 |
390 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
69 |
$3K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D1354 |
|
37 |
13 |
$555.00 |