| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,029 |
3,991 |
$242K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,225 |
1,184 |
$156K |
| D0330 |
Panoramic radiographic image |
1,732 |
1,711 |
$124K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,328 |
2,320 |
$76K |
| D1351 |
Sealant - per tooth |
2,975 |
644 |
$71K |
| D7140 |
Extraction, erupted tooth or exposed root |
821 |
455 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,391 |
2,351 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,416 |
3,371 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,029 |
679 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
404 |
185 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,102 |
1,074 |
$42K |
| D1110 |
Prophylaxis - adult |
668 |
659 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
477 |
357 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,748 |
1,723 |
$39K |
| D0274 |
Bitewings - four radiographic images |
658 |
653 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
430 |
426 |
$19K |
| D2330 |
|
229 |
145 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
920 |
907 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
995 |
514 |
$9K |
| D2332 |
|
102 |
74 |
$9K |
| D2331 |
|
97 |
72 |
$7K |
| D2335 |
|
59 |
27 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
84 |
56 |
$6K |
| D9420 |
|
67 |
65 |
$3K |
| D1206 |
Topical application of fluoride varnish |
45 |
45 |
$843.75 |