| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,730 |
5,516 |
$237K |
| D1351 |
Sealant - per tooth |
7,635 |
1,280 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,760 |
1,047 |
$203K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,499 |
545 |
$178K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,648 |
897 |
$153K |
| D1206 |
Topical application of fluoride varnish |
6,859 |
6,593 |
$145K |
| D0330 |
Panoramic radiographic image |
2,104 |
2,018 |
$145K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,497 |
743 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
3,880 |
3,749 |
$103K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,259 |
2,070 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,283 |
2,197 |
$84K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
939 |
446 |
$82K |
| D0140 |
Limited oral evaluation - problem focused |
1,947 |
1,836 |
$72K |
| D0272 |
Bitewings - two radiographic images |
2,739 |
2,628 |
$69K |
| D1110 |
Prophylaxis - adult |
1,114 |
1,073 |
$63K |
| D0274 |
Bitewings - four radiographic images |
777 |
747 |
$30K |
| D0145 |
Oral evaluation for a patient under three years of age |
558 |
547 |
$15K |
| D1354 |
|
241 |
110 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
473 |
438 |
$6K |
| D9420 |
|
145 |
136 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
586 |
166 |
$4K |
| D1510 |
|
19 |
14 |
$3K |
| D2330 |
|
38 |
26 |
$3K |
| D0350 |
|
45 |
38 |
$520.00 |
| D1310 |
|
23 |
19 |
$0.00 |
| D1330 |
|
17 |
17 |
$0.00 |