| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,867 |
7,865 |
$406K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,463 |
4,461 |
$297K |
| D1351 |
Sealant - per tooth |
5,030 |
1,560 |
$191K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,602 |
672 |
$191K |
| D1310 |
|
4,007 |
4,006 |
$183K |
| D0120 |
Periodic oral evaluation - established patient |
2,132 |
2,132 |
$139K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,134 |
3,071 |
$125K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,325 |
6,300 |
$123K |
| D1206 |
Topical application of fluoride varnish |
3,349 |
3,349 |
$104K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,437 |
763 |
$96K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,123 |
1,123 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,091 |
4,089 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
4,214 |
4,200 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
946 |
946 |
$45K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
442 |
210 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
693 |
453 |
$40K |
| D0603 |
|
2,462 |
2,461 |
$37K |
| D0350 |
|
2,047 |
1,888 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
443 |
244 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
464 |
293 |
$25K |
| D2140 |
|
438 |
267 |
$24K |
| D0602 |
|
1,009 |
1,009 |
$15K |
| D1320 |
|
1,483 |
1,483 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,121 |
1,119 |
$13K |
| D0274 |
Bitewings - four radiographic images |
564 |
563 |
$12K |
| D2330 |
|
63 |
43 |
$5K |
| D2331 |
|
31 |
22 |
$2K |
| D9430 |
|
13 |
13 |
$416.00 |