| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
17,424 |
17,305 |
$497K |
| D1208 |
Topical application of fluoride, excluding varnish |
24,296 |
24,113 |
$423K |
| D0120 |
Periodic oral evaluation - established patient |
23,154 |
22,976 |
$391K |
| D1110 |
Prophylaxis - adult |
7,027 |
6,960 |
$264K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,340 |
348 |
$200K |
| D0330 |
Panoramic radiographic image |
2,942 |
2,915 |
$132K |
| D0272 |
Bitewings - two radiographic images |
7,349 |
7,307 |
$129K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,678 |
1,025 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,046 |
2,041 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
815 |
514 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
1,650 |
1,620 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
310 |
141 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,411 |
1,390 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,867 |
1,836 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
140 |
$9K |
| D1351 |
Sealant - per tooth |
265 |
91 |
$9K |
| D7111 |
|
362 |
272 |
$6K |
| D0240 |
|
658 |
650 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
129 |
127 |
$4K |
| D9310 |
|
12 |
12 |
$1K |
| D9630 |
|
13 |
13 |
$258.31 |