| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
35,610 |
34,052 |
$784K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,881 |
2,013 |
$763K |
| D7140 |
Extraction, erupted tooth or exposed root |
9,985 |
4,772 |
$676K |
| D0120 |
Periodic oral evaluation - established patient |
34,515 |
33,031 |
$663K |
| D1206 |
Topical application of fluoride varnish |
24,582 |
23,568 |
$437K |
| D1351 |
Sealant - per tooth |
16,291 |
4,240 |
$414K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
5,819 |
3,131 |
$313K |
| D0330 |
Panoramic radiographic image |
5,164 |
4,908 |
$260K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,896 |
16,125 |
$255K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
8,984 |
8,581 |
$252K |
| D2140 |
|
5,861 |
3,078 |
$241K |
| D1110 |
Prophylaxis - adult |
6,197 |
5,929 |
$228K |
| D0272 |
Bitewings - two radiographic images |
21,723 |
20,730 |
$228K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,462 |
1,207 |
$186K |
| D0274 |
Bitewings - four radiographic images |
7,418 |
7,081 |
$156K |
| D0140 |
Limited oral evaluation - problem focused |
6,145 |
5,773 |
$154K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,195 |
690 |
$101K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,600 |
6,244 |
$94K |
| D0240 |
|
8,230 |
4,117 |
$91K |
| D0220 |
Intraoral - periapical first radiographic image |
11,877 |
10,719 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,036 |
938 |
$48K |
| D2332 |
|
513 |
318 |
$39K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
343 |
170 |
$28K |
| D0340 |
|
196 |
177 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
595 |
504 |
$19K |
| D8670 |
Periodic orthodontic treatment visit |
58 |
56 |
$13K |
| D2933 |
|
82 |
28 |
$11K |
| D0470 |
|
150 |
139 |
$6K |
| D2330 |
|
105 |
73 |
$6K |
| D0350 |
|
147 |
136 |
$3K |
| D2160 |
|
51 |
44 |
$3K |
| D1354 |
|
30 |
14 |
$884.40 |
| D0270 |
|
30 |
30 |
$150.00 |
| D1330 |
|
63 |
63 |
$0.00 |