| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,904 |
7,903 |
$264K |
| D1351 |
Sealant - per tooth |
3,676 |
1,463 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
7,308 |
7,307 |
$163K |
| D1110 |
Prophylaxis - adult |
3,484 |
3,484 |
$139K |
| D0274 |
Bitewings - four radiographic images |
6,511 |
6,510 |
$134K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,829 |
1,260 |
$113K |
| D0210 |
Intraoral - complete series of radiographic images |
3,928 |
3,924 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,705 |
6,703 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,360 |
3,360 |
$73K |
| D1206 |
Topical application of fluoride varnish |
2,769 |
2,768 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
5,797 |
5,786 |
$66K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
567 |
457 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,585 |
4,581 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
931 |
741 |
$43K |
| D0330 |
Panoramic radiographic image |
1,165 |
1,165 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
721 |
498 |
$29K |
| D4341 |
|
399 |
145 |
$21K |
| D9310 |
|
419 |
419 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
253 |
207 |
$17K |
| D9920 |
|
2,518 |
2,357 |
$5K |
| D0272 |
Bitewings - two radiographic images |
374 |
374 |
$4K |
| D0160 |
|
109 |
109 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
97 |
97 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$381.82 |
| D1999 |
|
1,200 |
1,128 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
162 |
153 |
$0.00 |
| D1330 |
|
4,842 |
4,842 |
$0.00 |
| D1310 |
|
357 |
357 |
$0.00 |