| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,930 |
7,920 |
$307K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,827 |
1,152 |
$192K |
| D0120 |
Periodic oral evaluation - established patient |
6,364 |
6,362 |
$173K |
| D1206 |
Topical application of fluoride varnish |
8,417 |
8,370 |
$151K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,228 |
515 |
$124K |
| D1351 |
Sealant - per tooth |
3,670 |
1,202 |
$115K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,770 |
906 |
$97K |
| D7140 |
Extraction, erupted tooth or exposed root |
996 |
514 |
$77K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,059 |
432 |
$75K |
| D0272 |
Bitewings - two radiographic images |
3,616 |
3,612 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,280 |
1,277 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,803 |
1,752 |
$46K |
| D0240 |
|
2,406 |
1,408 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,014 |
1,218 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
743 |
733 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,946 |
1,936 |
$24K |
| D1110 |
Prophylaxis - adult |
497 |
497 |
$23K |
| D0330 |
Panoramic radiographic image |
534 |
533 |
$19K |
| D0274 |
Bitewings - four radiographic images |
646 |
646 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
504 |
504 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
123 |
$7K |
| D0270 |
|
486 |
485 |
$5K |
| D1354 |
|
1,435 |
297 |
$4K |
| D1999 |
|
43 |
43 |
$301.00 |