| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,386 |
7,164 |
$336K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,176 |
484 |
$214K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,225 |
7,016 |
$198K |
| D0120 |
Periodic oral evaluation - established patient |
5,756 |
5,616 |
$166K |
| D8670 |
Periodic orthodontic treatment visit |
853 |
751 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,936 |
1,860 |
$108K |
| D1351 |
Sealant - per tooth |
2,234 |
721 |
$81K |
| D0272 |
Bitewings - two radiographic images |
2,764 |
2,687 |
$78K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,344 |
2,015 |
$72K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
783 |
395 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
654 |
401 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
635 |
319 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
1,327 |
1,264 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,121 |
1,087 |
$45K |
| D0330 |
Panoramic radiographic image |
644 |
606 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
2,109 |
2,017 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
428 |
276 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,576 |
1,138 |
$21K |
| D1110 |
Prophylaxis - adult |
197 |
195 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
86 |
49 |
$9K |
| D1206 |
Topical application of fluoride varnish |
304 |
297 |
$6K |
| D8660 |
|
106 |
93 |
$3K |
| D1999 |
|
86 |
78 |
$0.00 |