| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,188 |
9,188 |
$320K |
| D0120 |
Periodic oral evaluation - established patient |
12,105 |
12,105 |
$282K |
| D1110 |
Prophylaxis - adult |
5,012 |
5,012 |
$252K |
| D1206 |
Topical application of fluoride varnish |
12,574 |
12,574 |
$205K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,910 |
1,105 |
$189K |
| D0272 |
Bitewings - two radiographic images |
4,914 |
4,914 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,074 |
692 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,871 |
1,871 |
$76K |
| D1351 |
Sealant - per tooth |
2,548 |
622 |
$74K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,064 |
2,045 |
$65K |
| D0330 |
Panoramic radiographic image |
1,224 |
1,224 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,103 |
2,103 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,261 |
1,491 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,479 |
2,462 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
199 |
142 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
394 |
390 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
66 |
50 |
$8K |
| D9248 |
|
96 |
94 |
$6K |
| D0240 |
|
355 |
349 |
$5K |
| D2332 |
|
18 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
15 |
$2K |