| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,555 |
15,555 |
$546K |
| D0120 |
Periodic oral evaluation - established patient |
15,022 |
15,022 |
$357K |
| D1206 |
Topical application of fluoride varnish |
16,913 |
16,913 |
$280K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,438 |
1,480 |
$255K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,767 |
993 |
$228K |
| D9248 |
|
1,691 |
1,683 |
$122K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,226 |
807 |
$101K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,132 |
3,099 |
$101K |
| D1110 |
Prophylaxis - adult |
1,888 |
1,888 |
$95K |
| D0330 |
Panoramic radiographic image |
1,745 |
1,745 |
$89K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,440 |
1,440 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,670 |
2,670 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
507 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,443 |
1,443 |
$60K |
| D1351 |
Sealant - per tooth |
1,986 |
548 |
$60K |
| D0272 |
Bitewings - two radiographic images |
2,837 |
2,837 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
4,072 |
4,025 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,650 |
1,841 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
968 |
968 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
81 |
$10K |
| D9420 |
|
75 |
75 |
$6K |
| D1354 |
|
517 |
138 |
$5K |
| D7111 |
|
12 |
12 |
$804.00 |
| D9920 |
|
12 |
12 |
$770.00 |