| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,278 |
6,120 |
$127K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,234 |
379 |
$107K |
| D1206 |
Topical application of fluoride varnish |
7,185 |
7,018 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,605 |
853 |
$90K |
| D1355 |
|
2,288 |
508 |
$77K |
| D1351 |
Sealant - per tooth |
2,826 |
815 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,282 |
549 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
4,800 |
4,729 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,809 |
1,742 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,533 |
2,347 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
583 |
297 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,841 |
1,693 |
$35K |
| D0240 |
|
3,623 |
1,806 |
$33K |
| D1110 |
Prophylaxis - adult |
917 |
909 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
223 |
101 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
1,384 |
1,168 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,794 |
2,703 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,070 |
1,049 |
$14K |
| D9310 |
|
148 |
148 |
$11K |
| D9630 |
|
799 |
785 |
$9K |
| D1354 |
|
3,284 |
804 |
$9K |
| D3120 |
|
500 |
249 |
$9K |
| D0274 |
Bitewings - four radiographic images |
433 |
430 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
445 |
426 |
$6K |
| D9920 |
|
52 |
46 |
$4K |
| D8660 |
|
57 |
57 |
$3K |
| D1510 |
|
19 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
13 |
$525.52 |
| D8670 |
Periodic orthodontic treatment visit |
81 |
81 |
$0.00 |
| D0330 |
Panoramic radiographic image |
148 |
148 |
$0.00 |