| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,359 |
8,359 |
$290K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,037 |
597 |
$252K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,045 |
1,460 |
$207K |
| D0120 |
Periodic oral evaluation - established patient |
8,861 |
8,861 |
$203K |
| D1206 |
Topical application of fluoride varnish |
10,626 |
10,626 |
$172K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,580 |
747 |
$137K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,680 |
1,158 |
$130K |
| D1110 |
Prophylaxis - adult |
2,275 |
2,275 |
$114K |
| D0272 |
Bitewings - two radiographic images |
5,891 |
5,891 |
$111K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,246 |
3,154 |
$104K |
| D7240 |
Removal of impacted tooth - completely bony |
356 |
108 |
$99K |
| D0220 |
Intraoral - periapical first radiographic image |
5,162 |
5,141 |
$66K |
| D0330 |
Panoramic radiographic image |
1,233 |
1,233 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,454 |
1,454 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,240 |
3,263 |
$54K |
| D9248 |
|
552 |
550 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
865 |
862 |
$33K |
| D9420 |
|
278 |
278 |
$24K |
| D1351 |
Sealant - per tooth |
620 |
216 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
423 |
423 |
$15K |
| D9239 |
|
158 |
158 |
$12K |
| D9243 |
|
156 |
156 |
$12K |
| D7230 |
|
25 |
12 |
$6K |
| D0274 |
Bitewings - four radiographic images |
148 |
148 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
42 |
24 |
$3K |