| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,430 |
12,090 |
$760K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,163 |
1,059 |
$737K |
| D0120 |
Periodic oral evaluation - established patient |
12,499 |
12,159 |
$571K |
| D1206 |
Topical application of fluoride varnish |
10,884 |
10,553 |
$294K |
| D0274 |
Bitewings - four radiographic images |
5,028 |
4,898 |
$286K |
| D0272 |
Bitewings - two radiographic images |
6,862 |
6,664 |
$266K |
| D1351 |
Sealant - per tooth |
4,161 |
1,209 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,021 |
633 |
$170K |
| D1110 |
Prophylaxis - adult |
1,813 |
1,755 |
$143K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,098 |
717 |
$141K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,064 |
1,667 |
$106K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,018 |
1,732 |
$100K |
| D0330 |
Panoramic radiographic image |
1,042 |
1,005 |
$97K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,549 |
2,470 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,027 |
992 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
2,556 |
2,428 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
340 |
173 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
196 |
$12K |
| D9248 |
|
42 |
41 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
135 |
133 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
24 |
$4K |
| D2330 |
|
28 |
13 |
$3K |
| D2331 |
|
20 |
12 |
$3K |
| D9310 |
|
12 |
12 |
$1K |