| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,502 |
4,206 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,396 |
306 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
3,817 |
3,560 |
$18K |
| D1206 |
Topical application of fluoride varnish |
4,325 |
3,988 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,227 |
392 |
$18K |
| D1354 |
|
4,119 |
653 |
$15K |
| D0272 |
Bitewings - two radiographic images |
3,480 |
3,122 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
4,597 |
4,125 |
$11K |
| D1351 |
Sealant - per tooth |
1,733 |
426 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,626 |
3,906 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
598 |
179 |
$8K |
| D0330 |
Panoramic radiographic image |
699 |
623 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
582 |
539 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
129 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,022 |
776 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
452 |
417 |
$3K |
| D1110 |
Prophylaxis - adult |
340 |
295 |
$3K |
| D0274 |
Bitewings - four radiographic images |
586 |
518 |
$3K |
| D9248 |
|
170 |
123 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
100 |
$1K |
| D2332 |
|
56 |
27 |
$872.95 |
| D2331 |
|
19 |
12 |
$331.76 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
76 |
25 |
$134.00 |
| D1999 |
|
35 |
31 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
465 |
452 |
$0.00 |
| D1330 |
|
355 |
346 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
445 |
383 |
$0.00 |
| D0240 |
|
53 |
27 |
$0.00 |