| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
14,821 |
14,821 |
$515K |
| D0120 |
Periodic oral evaluation - established patient |
18,462 |
18,462 |
$431K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,419 |
2,433 |
$354K |
| D1206 |
Topical application of fluoride varnish |
20,196 |
20,196 |
$330K |
| D1110 |
Prophylaxis - adult |
5,659 |
5,659 |
$284K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,802 |
6,626 |
$216K |
| D0272 |
Bitewings - two radiographic images |
11,102 |
11,102 |
$209K |
| D1351 |
Sealant - per tooth |
5,605 |
1,667 |
$165K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,244 |
944 |
$99K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
686 |
389 |
$84K |
| D0330 |
Panoramic radiographic image |
1,808 |
1,798 |
$80K |
| D0274 |
Bitewings - four radiographic images |
2,301 |
2,301 |
$64K |
| D9248 |
|
939 |
913 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,436 |
1,436 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
3,577 |
3,541 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
466 |
298 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,200 |
1,422 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
469 |
465 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
130 |
130 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
39 |
29 |
$3K |
| D0240 |
|
99 |
94 |
$2K |