| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,656 |
8,353 |
$253K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,115 |
579 |
$233K |
| D1351 |
Sealant - per tooth |
8,726 |
1,953 |
$209K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,479 |
846 |
$180K |
| D1206 |
Topical application of fluoride varnish |
9,919 |
9,565 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
6,973 |
6,768 |
$149K |
| D0272 |
Bitewings - two radiographic images |
5,902 |
5,706 |
$120K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,882 |
2,757 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,026 |
648 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
919 |
556 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,505 |
2,098 |
$65K |
| D0330 |
Panoramic radiographic image |
1,743 |
1,674 |
$58K |
| D1110 |
Prophylaxis - adult |
1,423 |
1,385 |
$57K |
| D2140 |
|
1,040 |
581 |
$45K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
823 |
468 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,143 |
1,109 |
$34K |
| D0240 |
|
1,502 |
847 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,432 |
2,008 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
463 |
436 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,054 |
792 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
12 |
$1K |
| D9310 |
|
16 |
15 |
$330.00 |
| D7111 |
|
42 |
26 |
$0.00 |
| D1353 |
|
55 |
27 |
$0.00 |