| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,296 |
12,965 |
$738K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,277 |
1,432 |
$503K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,521 |
3,219 |
$455K |
| D0120 |
Periodic oral evaluation - established patient |
11,964 |
11,658 |
$292K |
| D1206 |
Topical application of fluoride varnish |
14,116 |
13,741 |
$249K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,021 |
1,556 |
$187K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,965 |
4,369 |
$176K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,065 |
1,753 |
$170K |
| D0330 |
Panoramic radiographic image |
2,430 |
2,357 |
$128K |
| D1351 |
Sealant - per tooth |
5,777 |
2,000 |
$125K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,550 |
3,425 |
$108K |
| D0272 |
Bitewings - two radiographic images |
5,377 |
5,212 |
$105K |
| D1110 |
Prophylaxis - adult |
1,965 |
1,914 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,136 |
2,164 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
4,174 |
3,754 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
971 |
908 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,316 |
1,265 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
574 |
302 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
307 |
211 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
936 |
903 |
$14K |
| D2332 |
|
149 |
67 |
$12K |
| D9420 |
|
127 |
106 |
$6K |
| D1354 |
|
34 |
17 |
$374.00 |
| D3120 |
|
42 |
27 |
$0.00 |