| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
20,147 |
20,147 |
$706K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,289 |
2,755 |
$553K |
| D0120 |
Periodic oral evaluation - established patient |
20,334 |
20,334 |
$479K |
| D1208 |
Topical application of fluoride, excluding varnish |
27,370 |
27,370 |
$450K |
| D1110 |
Prophylaxis - adult |
7,404 |
7,404 |
$376K |
| D1351 |
Sealant - per tooth |
12,117 |
3,477 |
$366K |
| D0272 |
Bitewings - two radiographic images |
18,109 |
18,109 |
$344K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
9,207 |
8,992 |
$301K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,144 |
2,253 |
$267K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,655 |
1,693 |
$265K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,985 |
2,150 |
$236K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,564 |
5,564 |
$229K |
| D0330 |
Panoramic radiographic image |
3,965 |
3,965 |
$174K |
| D0274 |
Bitewings - four radiographic images |
5,111 |
5,111 |
$144K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,288 |
946 |
$135K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,243 |
2,243 |
$97K |
| D0140 |
Limited oral evaluation - problem focused |
2,180 |
2,170 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
4,640 |
4,552 |
$61K |
| D7111 |
|
668 |
458 |
$45K |
| D2140 |
|
631 |
460 |
$37K |
| D0240 |
|
1,501 |
1,320 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,983 |
1,327 |
$21K |
| D2330 |
|
166 |
120 |
$11K |
| D1510 |
|
58 |
51 |
$10K |
| D2331 |
|
20 |
13 |
$2K |