| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,715 |
10,711 |
$356K |
| D1206 |
Topical application of fluoride varnish |
14,028 |
14,021 |
$265K |
| D0120 |
Periodic oral evaluation - established patient |
10,205 |
10,204 |
$243K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,729 |
523 |
$218K |
| D1110 |
Prophylaxis - adult |
2,594 |
2,594 |
$118K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,271 |
2,269 |
$89K |
| D0272 |
Bitewings - two radiographic images |
4,066 |
4,064 |
$85K |
| D0330 |
Panoramic radiographic image |
1,129 |
1,129 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,395 |
1,366 |
$44K |
| D0240 |
|
727 |
727 |
$28K |
| D0274 |
Bitewings - four radiographic images |
869 |
869 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
174 |
99 |
$18K |
| D2140 |
|
161 |
90 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
56 |
27 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
233 |
233 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
198 |
$7K |
| D1351 |
Sealant - per tooth |
167 |
52 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
42 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
411 |
410 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$867.45 |