| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,112 |
8,112 |
$279K |
| D0120 |
Periodic oral evaluation - established patient |
8,012 |
8,012 |
$187K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,792 |
814 |
$183K |
| D1206 |
Topical application of fluoride varnish |
9,224 |
9,224 |
$150K |
| D1110 |
Prophylaxis - adult |
2,254 |
2,254 |
$111K |
| D9920 |
|
2,064 |
2,050 |
$111K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
636 |
198 |
$82K |
| D0274 |
Bitewings - four radiographic images |
2,690 |
2,690 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,783 |
1,783 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,919 |
1,859 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,412 |
1,388 |
$54K |
| D0272 |
Bitewings - two radiographic images |
2,773 |
2,773 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,812 |
2,631 |
$49K |
| D0330 |
Panoramic radiographic image |
1,016 |
1,016 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,471 |
3,439 |
$44K |
| D1351 |
Sealant - per tooth |
1,283 |
428 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
256 |
134 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
269 |
131 |
$30K |
| D9248 |
|
312 |
308 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
368 |
368 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,073 |
1,073 |
$17K |
| D0240 |
|
1,174 |
649 |
$16K |
| D2330 |
|
130 |
50 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
77 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
82 |
40 |
$7K |
| D9420 |
|
71 |
71 |
$6K |
| D0160 |
|
54 |
53 |
$5K |