| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,012 |
4,921 |
$126K |
| D1120 |
Prophylaxis - child |
3,855 |
3,781 |
$119K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
780 |
174 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,468 |
4,377 |
$83K |
| D1110 |
Prophylaxis - adult |
1,306 |
1,276 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,652 |
2,541 |
$48K |
| D1351 |
Sealant - per tooth |
791 |
231 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
227 |
84 |
$20K |
| D7111 |
|
328 |
138 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,362 |
1,199 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
65 |
$10K |
| D1206 |
Topical application of fluoride varnish |
389 |
388 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
276 |
232 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
62 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
946 |
320 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
79 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
220 |
214 |
$3K |
| D9420 |
|
36 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$679.45 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$627.84 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$538.86 |