| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,187 |
8,187 |
$260K |
| D1206 |
Topical application of fluoride varnish |
8,887 |
8,882 |
$210K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,118 |
1,878 |
$166K |
| D1351 |
Sealant - per tooth |
3,455 |
1,317 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
5,974 |
5,969 |
$125K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,597 |
1,017 |
$122K |
| D0220 |
Intraoral - periapical first radiographic image |
8,501 |
8,445 |
$87K |
| D1110 |
Prophylaxis - adult |
2,089 |
2,084 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,128 |
3,128 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,220 |
8,204 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,760 |
1,156 |
$58K |
| D0274 |
Bitewings - four radiographic images |
2,389 |
2,388 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,182 |
875 |
$43K |
| D0272 |
Bitewings - two radiographic images |
3,480 |
3,478 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
2,577 |
2,512 |
$27K |
| D9310 |
|
434 |
434 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
542 |
542 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
934 |
920 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
143 |
105 |
$8K |
| D1354 |
|
491 |
148 |
$7K |
| D0330 |
Panoramic radiographic image |
218 |
218 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
409 |
409 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
51 |
$4K |
| D8660 |
|
130 |
130 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
34 |
$2K |
| D0340 |
|
56 |
56 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
31 |
$1K |
| D0350 |
|
84 |
84 |
$760.60 |
| D2330 |
|
21 |
12 |
$640.35 |
| D4342 |
|
18 |
12 |
$543.60 |