| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
12,189 |
12,188 |
$338K |
| D1120 |
Prophylaxis - child |
7,436 |
7,436 |
$205K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,579 |
1,422 |
$185K |
| D1206 |
Topical application of fluoride varnish |
7,284 |
7,284 |
$153K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,595 |
2,482 |
$137K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,037 |
585 |
$90K |
| D0220 |
Intraoral - periapical first radiographic image |
6,424 |
6,402 |
$72K |
| D0272 |
Bitewings - two radiographic images |
3,841 |
3,841 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,761 |
4,603 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
587 |
397 |
$41K |
| D1351 |
Sealant - per tooth |
1,262 |
419 |
$33K |
| D0330 |
Panoramic radiographic image |
634 |
634 |
$32K |
| D0274 |
Bitewings - four radiographic images |
808 |
808 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
658 |
658 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
289 |
206 |
$14K |
| D1110 |
Prophylaxis - adult |
319 |
319 |
$12K |
| D0240 |
|
495 |
495 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
273 |
269 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
93 |
70 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
65 |
65 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$847.56 |
| D1354 |
|
81 |
25 |
$546.66 |