| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,459 |
5,218 |
$146K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,060 |
428 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,245 |
880 |
$127K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,415 |
2,164 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,364 |
2,231 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,705 |
5,430 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
3,393 |
3,253 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
816 |
600 |
$64K |
| D1351 |
Sealant - per tooth |
2,321 |
694 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
3,149 |
2,882 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
1,082 |
1,009 |
$38K |
| D0272 |
Bitewings - two radiographic images |
2,215 |
2,100 |
$38K |
| D0240 |
|
2,065 |
992 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,795 |
1,132 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
445 |
220 |
$27K |
| D0170 |
|
383 |
356 |
$11K |
| D0330 |
Panoramic radiographic image |
178 |
163 |
$10K |
| D1354 |
|
2,214 |
537 |
$9K |
| D1110 |
Prophylaxis - adult |
256 |
235 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
334 |
217 |
$7K |
| D1206 |
Topical application of fluoride varnish |
262 |
261 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
26 |
$3K |
| D9420 |
|
13 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$436.15 |
| D1330 |
|
1,969 |
1,925 |
$0.00 |
| D1310 |
|
894 |
875 |
$0.00 |