| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,945 |
7,945 |
$275K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,524 |
631 |
$192K |
| D0120 |
Periodic oral evaluation - established patient |
7,791 |
7,791 |
$178K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,783 |
1,008 |
$154K |
| D1206 |
Topical application of fluoride varnish |
9,001 |
9,001 |
$145K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,118 |
478 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
661 |
418 |
$68K |
| D9248 |
|
973 |
963 |
$63K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,893 |
1,856 |
$61K |
| D1110 |
Prophylaxis - adult |
1,205 |
1,205 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,989 |
1,989 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,342 |
1,342 |
$54K |
| D0330 |
Panoramic radiographic image |
1,051 |
1,051 |
$52K |
| D1351 |
Sealant - per tooth |
1,677 |
472 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,435 |
1,719 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,217 |
3,181 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
783 |
778 |
$30K |
| D0145 |
Oral evaluation for a patient under three years of age |
478 |
478 |
$17K |
| D0272 |
Bitewings - two radiographic images |
822 |
822 |
$15K |
| D2940 |
|
155 |
81 |
$7K |
| D9420 |
|
40 |
40 |
$3K |
| D1354 |
|
312 |
100 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |
| D0240 |
|
34 |
33 |
$625.02 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$601.08 |