| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
20,229 |
20,030 |
$666K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,828 |
2,654 |
$621K |
| D1206 |
Topical application of fluoride varnish |
22,731 |
22,487 |
$460K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,953 |
4,131 |
$405K |
| D0120 |
Periodic oral evaluation - established patient |
14,673 |
14,540 |
$351K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
11,456 |
9,801 |
$327K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,704 |
4,023 |
$322K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,752 |
1,884 |
$292K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,656 |
2,654 |
$265K |
| D0272 |
Bitewings - two radiographic images |
14,658 |
14,510 |
$257K |
| D1110 |
Prophylaxis - adult |
3,732 |
3,676 |
$154K |
| D0330 |
Panoramic radiographic image |
2,490 |
2,452 |
$111K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,726 |
2,694 |
$76K |
| D1351 |
Sealant - per tooth |
1,888 |
688 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
3,103 |
3,019 |
$37K |
| D2390 |
|
208 |
60 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
303 |
291 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
37 |
$4K |
| D2330 |
|
19 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
28 |
$312.00 |