| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,350 |
6,188 |
$288K |
| D1206 |
Topical application of fluoride varnish |
6,128 |
5,984 |
$192K |
| D0120 |
Periodic oral evaluation - established patient |
4,495 |
4,377 |
$170K |
| D1351 |
Sealant - per tooth |
5,094 |
1,010 |
$145K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,126 |
470 |
$133K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,340 |
712 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,379 |
889 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,455 |
1,431 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,677 |
2,218 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,176 |
2,129 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
3,556 |
3,334 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
745 |
479 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,379 |
2,763 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
533 |
510 |
$24K |
| D0603 |
|
2,265 |
2,194 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
157 |
$11K |
| D0330 |
Panoramic radiographic image |
357 |
345 |
$9K |
| D0274 |
Bitewings - four radiographic images |
585 |
557 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
82 |
41 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
233 |
218 |
$5K |
| D0601 |
|
324 |
319 |
$3K |
| D9420 |
|
63 |
63 |
$2K |
| D1110 |
Prophylaxis - adult |
152 |
145 |
$2K |
| D0602 |
|
64 |
64 |
$640.00 |
| D1354 |
|
134 |
43 |
$525.00 |
| D0240 |
|
21 |
21 |
$420.00 |