| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,119 |
13,119 |
$452K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,863 |
2,637 |
$406K |
| D0120 |
Periodic oral evaluation - established patient |
13,882 |
13,882 |
$325K |
| D1206 |
Topical application of fluoride varnish |
17,415 |
17,415 |
$285K |
| D1110 |
Prophylaxis - adult |
4,549 |
4,549 |
$227K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,312 |
1,751 |
$196K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,891 |
5,525 |
$186K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,274 |
856 |
$161K |
| D0272 |
Bitewings - two radiographic images |
5,388 |
5,388 |
$102K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,017 |
607 |
$91K |
| D0274 |
Bitewings - four radiographic images |
3,072 |
3,072 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,051 |
2,051 |
$84K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,722 |
1,722 |
$79K |
| D0140 |
Limited oral evaluation - problem focused |
1,803 |
1,801 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
2,400 |
2,388 |
$31K |
| D0240 |
|
1,458 |
1,255 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
238 |
185 |
$19K |
| D1351 |
Sealant - per tooth |
492 |
130 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,512 |
662 |
$10K |
| D9420 |
|
85 |
85 |
$7K |
| D2331 |
|
16 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$901.62 |