| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
28,480 |
28,479 |
$991K |
| D0120 |
Periodic oral evaluation - established patient |
27,318 |
27,317 |
$637K |
| D1206 |
Topical application of fluoride varnish |
36,426 |
36,425 |
$596K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,107 |
2,906 |
$413K |
| D1110 |
Prophylaxis - adult |
8,102 |
8,102 |
$410K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
9,967 |
9,633 |
$316K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,407 |
6,406 |
$264K |
| D0272 |
Bitewings - two radiographic images |
10,457 |
10,457 |
$198K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,579 |
694 |
$193K |
| D0330 |
Panoramic radiographic image |
3,512 |
3,512 |
$177K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,863 |
1,536 |
$145K |
| D0274 |
Bitewings - four radiographic images |
4,247 |
4,247 |
$118K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,625 |
2,625 |
$100K |
| D0220 |
Intraoral - periapical first radiographic image |
4,919 |
4,896 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
705 |
426 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,979 |
2,264 |
$57K |
| D1351 |
Sealant - per tooth |
1,867 |
561 |
$55K |
| D0240 |
|
2,474 |
1,458 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
295 |
$11K |
| D9420 |
|
109 |
109 |
$9K |
| D9248 |
|
137 |
137 |
$9K |
| D7111 |
|
115 |
66 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
59 |
24 |
$5K |