| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,248 |
6,189 |
$301K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,539 |
987 |
$189K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,140 |
6,072 |
$161K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,936 |
1,118 |
$128K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,292 |
3,177 |
$126K |
| D0272 |
Bitewings - two radiographic images |
6,031 |
5,962 |
$111K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,252 |
7,177 |
$110K |
| D1351 |
Sealant - per tooth |
3,070 |
691 |
$60K |
| D0330 |
Panoramic radiographic image |
1,507 |
1,485 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,125 |
792 |
$57K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
810 |
565 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
723 |
579 |
$51K |
| D1110 |
Prophylaxis - adult |
1,064 |
1,048 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,340 |
1,329 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,845 |
1,782 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
548 |
530 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
165 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
784 |
618 |
$6K |
| D2331 |
|
36 |
27 |
$3K |
| D9986 |
|
1,585 |
1,287 |
$0.00 |
| D9987 |
|
573 |
479 |
$0.00 |