| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,666 |
10,665 |
$438K |
| D0120 |
Periodic oral evaluation - established patient |
10,636 |
10,635 |
$260K |
| D1351 |
Sealant - per tooth |
6,646 |
1,609 |
$202K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,508 |
1,327 |
$163K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,286 |
816 |
$144K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,915 |
9,914 |
$134K |
| D1354 |
|
6,796 |
1,205 |
$93K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,713 |
1,088 |
$83K |
| D1110 |
Prophylaxis - adult |
1,804 |
1,804 |
$79K |
| D1206 |
Topical application of fluoride varnish |
2,415 |
2,415 |
$56K |
| D0272 |
Bitewings - two radiographic images |
3,832 |
3,830 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
6,451 |
6,441 |
$51K |
| D0330 |
Panoramic radiographic image |
1,612 |
1,595 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,567 |
1,567 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,108 |
6,096 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
758 |
442 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,361 |
1,361 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
1,002 |
993 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
197 |
153 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
72 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
87 |
87 |
$3K |
| D0601 |
|
1,333 |
1,332 |
$908.00 |
| D0602 |
|
1,059 |
1,059 |
$755.00 |
| D9310 |
|
15 |
14 |
$420.00 |
| D0603 |
|
432 |
432 |
$354.00 |
| D3120 |
|
15 |
14 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
216 |
198 |
$0.00 |
| D1999 |
|
244 |
231 |
$0.00 |