| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
34,469 |
34,469 |
$1.19M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
10,225 |
7,118 |
$1.02M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
7,455 |
3,369 |
$933K |
| D0120 |
Periodic oral evaluation - established patient |
33,680 |
33,680 |
$777K |
| D1206 |
Topical application of fluoride varnish |
40,459 |
40,459 |
$655K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18,379 |
17,800 |
$580K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,928 |
2,867 |
$458K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,487 |
4,292 |
$439K |
| D1110 |
Prophylaxis - adult |
7,366 |
7,366 |
$352K |
| D0272 |
Bitewings - two radiographic images |
17,227 |
17,227 |
$322K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,119 |
1,776 |
$251K |
| D0145 |
Oral evaluation for a patient under three years of age |
5,462 |
5,462 |
$249K |
| D9248 |
|
3,251 |
3,208 |
$225K |
| D1351 |
Sealant - per tooth |
7,846 |
2,849 |
$223K |
| D0330 |
Panoramic radiographic image |
4,397 |
4,397 |
$219K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,753 |
1,753 |
$69K |
| D0140 |
Limited oral evaluation - problem focused |
1,821 |
1,813 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
4,151 |
4,125 |
$52K |
| D2934 |
|
291 |
108 |
$36K |
| D2331 |
|
368 |
254 |
$31K |
| D2330 |
|
386 |
273 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
114 |
104 |
$14K |
| D0240 |
|
476 |
415 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
137 |
$3K |
| D1510 |
|
15 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$1K |
| D9420 |
|
12 |
12 |
$1K |
| D9920 |
|
12 |
12 |
$620.40 |