| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,662 |
10,744 |
$353K |
| D1206 |
Topical application of fluoride varnish |
15,656 |
14,444 |
$314K |
| D0120 |
Periodic oral evaluation - established patient |
14,523 |
13,399 |
$297K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,367 |
897 |
$296K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,310 |
1,820 |
$232K |
| D1110 |
Prophylaxis - adult |
4,199 |
3,858 |
$177K |
| D1351 |
Sealant - per tooth |
5,864 |
837 |
$151K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,182 |
994 |
$138K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,421 |
602 |
$116K |
| D0272 |
Bitewings - two radiographic images |
5,112 |
4,721 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,922 |
3,273 |
$108K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,906 |
1,112 |
$86K |
| D0330 |
Panoramic radiographic image |
1,194 |
1,102 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,294 |
1,171 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,167 |
1,031 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
898 |
803 |
$28K |
| D0240 |
|
913 |
781 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
772 |
705 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
551 |
366 |
$4K |
| D2335 |
|
38 |
14 |
$4K |
| D2332 |
|
42 |
24 |
$4K |
| D2330 |
|
34 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
40 |
$1K |
| D9248 |
|
31 |
24 |
$770.00 |
| D9420 |
|
126 |
117 |
$0.00 |
| D9310 |
|
48 |
44 |
$0.00 |