| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,225 |
6,943 |
$229K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,731 |
427 |
$204K |
| D1206 |
Topical application of fluoride varnish |
8,709 |
8,364 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
7,065 |
6,802 |
$157K |
| D1351 |
Sealant - per tooth |
6,705 |
1,573 |
$154K |
| D0272 |
Bitewings - two radiographic images |
5,146 |
4,931 |
$110K |
| D7140 |
Extraction, erupted tooth or exposed root |
836 |
380 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,138 |
1,896 |
$70K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,050 |
654 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
823 |
492 |
$60K |
| D1110 |
Prophylaxis - adult |
1,308 |
1,270 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,637 |
1,588 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
727 |
438 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,470 |
1,410 |
$45K |
| D0330 |
Panoramic radiographic image |
1,231 |
1,186 |
$41K |
| D2140 |
|
822 |
500 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
3,407 |
3,063 |
$36K |
| D0240 |
|
2,031 |
1,099 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,012 |
2,016 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
400 |
367 |
$11K |
| D1354 |
|
423 |
127 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
24 |
13 |
$1K |
| D7111 |
|
22 |
12 |
$0.00 |
| D1353 |
|
35 |
14 |
$0.00 |