| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,989 |
8,986 |
$307K |
| D0120 |
Periodic oral evaluation - established patient |
7,165 |
7,163 |
$157K |
| D1351 |
Sealant - per tooth |
2,874 |
1,151 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,655 |
1,184 |
$125K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,361 |
8,359 |
$98K |
| D1354 |
|
2,964 |
714 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,310 |
953 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,442 |
2,442 |
$57K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
601 |
403 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
5,062 |
5,049 |
$45K |
| D0272 |
Bitewings - two radiographic images |
3,069 |
3,069 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,637 |
4,626 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,244 |
1,244 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
437 |
367 |
$24K |
| D0330 |
Panoramic radiographic image |
832 |
832 |
$23K |
| D1110 |
Prophylaxis - adult |
586 |
586 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
244 |
216 |
$17K |
| D0274 |
Bitewings - four radiographic images |
703 |
703 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
963 |
948 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
101 |
101 |
$2K |
| D1999 |
|
213 |
212 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
32 |
27 |
$604.33 |
| D9996 |
|
14 |
14 |
$75.36 |
| D3120 |
|
15 |
13 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$0.00 |