| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,156 |
5,966 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
4,483 |
4,410 |
$118K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,587 |
6,379 |
$110K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,001 |
647 |
$105K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,281 |
2,055 |
$103K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,216 |
2,082 |
$97K |
| D1351 |
Sealant - per tooth |
2,833 |
809 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
554 |
223 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
722 |
520 |
$59K |
| D0272 |
Bitewings - two radiographic images |
2,421 |
2,290 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,811 |
2,569 |
$42K |
| D0240 |
|
2,360 |
1,146 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
920 |
885 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,633 |
1,008 |
$30K |
| D1110 |
Prophylaxis - adult |
608 |
592 |
$23K |
| D0330 |
Panoramic radiographic image |
284 |
263 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
220 |
109 |
$13K |
| D1354 |
|
1,814 |
474 |
$8K |
| D0170 |
|
218 |
210 |
$6K |
| D0274 |
Bitewings - four radiographic images |
132 |
131 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
194 |
142 |
$4K |
| D1206 |
Topical application of fluoride varnish |
159 |
150 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$1K |
| D1330 |
|
155 |
126 |
$0.00 |
| D1310 |
|
70 |
70 |
$0.00 |
| D9630 |
|
15 |
13 |
$0.00 |