| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,349 |
15,348 |
$643K |
| D0120 |
Periodic oral evaluation - established patient |
15,574 |
15,573 |
$446K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,915 |
2,843 |
$387K |
| D1206 |
Topical application of fluoride varnish |
10,805 |
10,804 |
$311K |
| D1110 |
Prophylaxis - adult |
4,178 |
4,178 |
$235K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,631 |
1,770 |
$228K |
| D1351 |
Sealant - per tooth |
4,650 |
1,565 |
$202K |
| D0272 |
Bitewings - two radiographic images |
10,097 |
10,097 |
$199K |
| D0274 |
Bitewings - four radiographic images |
3,959 |
3,959 |
$146K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,086 |
10,086 |
$144K |
| D0330 |
Panoramic radiographic image |
2,534 |
2,531 |
$113K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
541 |
217 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,767 |
1,767 |
$52K |
| D1354 |
|
1,404 |
392 |
$48K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,168 |
1,168 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
281 |
218 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,065 |
2,048 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
415 |
328 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
136 |
86 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
191 |
108 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
369 |
366 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
291 |
214 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
13 |
$2K |
| D0240 |
|
55 |
53 |
$843.00 |
| D2140 |
|
15 |
14 |
$804.45 |
| D0603 |
|
2,176 |
2,176 |
$0.00 |