| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
30,809 |
30,809 |
$1.08M |
| D0120 |
Periodic oral evaluation - established patient |
39,528 |
39,528 |
$924K |
| D1208 |
Topical application of fluoride, excluding varnish |
43,226 |
43,226 |
$707K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,404 |
3,587 |
$683K |
| D1110 |
Prophylaxis - adult |
12,485 |
12,485 |
$628K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,824 |
3,035 |
$387K |
| D0272 |
Bitewings - two radiographic images |
18,784 |
18,784 |
$357K |
| D0330 |
Panoramic radiographic image |
6,289 |
6,289 |
$319K |
| D0240 |
|
15,833 |
15,757 |
$313K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
9,530 |
9,164 |
$303K |
| D0274 |
Bitewings - four radiographic images |
10,585 |
10,585 |
$294K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,760 |
2,031 |
$279K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,395 |
1,066 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,178 |
2,178 |
$89K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,844 |
1,844 |
$83K |
| D0140 |
Limited oral evaluation - problem focused |
1,567 |
1,567 |
$60K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
697 |
502 |
$55K |
| D1351 |
Sealant - per tooth |
824 |
211 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,698 |
1,694 |
$22K |
| D2934 |
|
28 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
26 |
$282.16 |