| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
19,426 |
19,426 |
$667K |
| D7140 |
Extraction, erupted tooth or exposed root |
6,946 |
4,327 |
$633K |
| D0120 |
Periodic oral evaluation - established patient |
22,708 |
22,708 |
$524K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,236 |
2,707 |
$500K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,940 |
3,447 |
$479K |
| D1206 |
Topical application of fluoride varnish |
24,264 |
24,264 |
$391K |
| D9248 |
|
5,042 |
5,025 |
$338K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33,937 |
11,758 |
$323K |
| D1110 |
Prophylaxis - adult |
5,744 |
5,744 |
$285K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
9,035 |
8,899 |
$281K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,163 |
2,371 |
$248K |
| D1351 |
Sealant - per tooth |
6,558 |
2,267 |
$185K |
| D0220 |
Intraoral - periapical first radiographic image |
14,261 |
14,187 |
$181K |
| D0272 |
Bitewings - two radiographic images |
7,325 |
7,325 |
$137K |
| D0330 |
Panoramic radiographic image |
2,601 |
2,601 |
$128K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,946 |
1,946 |
$81K |
| D0140 |
Limited oral evaluation - problem focused |
2,026 |
2,006 |
$76K |
| D0240 |
|
4,846 |
3,494 |
$76K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
522 |
382 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
916 |
916 |
$36K |
| D0274 |
Bitewings - four radiographic images |
650 |
650 |
$18K |
| D7111 |
|
178 |
140 |
$12K |
| D2330 |
|
50 |
38 |
$3K |