| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,296 |
6,061 |
$349K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,701 |
569 |
$188K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,295 |
6,086 |
$185K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,953 |
1,183 |
$132K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,921 |
902 |
$124K |
| D0330 |
Panoramic radiographic image |
1,797 |
1,767 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,336 |
913 |
$73K |
| D0272 |
Bitewings - two radiographic images |
3,640 |
3,517 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,968 |
3,853 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,386 |
1,299 |
$51K |
| D1206 |
Topical application of fluoride varnish |
2,823 |
2,696 |
$50K |
| D1351 |
Sealant - per tooth |
2,184 |
755 |
$46K |
| D1110 |
Prophylaxis - adult |
508 |
494 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
912 |
892 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,509 |
1,450 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,687 |
600 |
$14K |
| D2331 |
|
103 |
72 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
62 |
41 |
$4K |
| D0274 |
Bitewings - four radiographic images |
113 |
110 |
$3K |
| D2332 |
|
30 |
24 |
$2K |
| D2330 |
|
38 |
24 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$404.25 |
| D9986 |
|
92 |
64 |
$120.00 |