| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,161 |
9,153 |
$361K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,906 |
1,383 |
$328K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,187 |
1,501 |
$248K |
| D1206 |
Topical application of fluoride varnish |
9,787 |
9,778 |
$245K |
| D1351 |
Sealant - per tooth |
7,790 |
1,505 |
$230K |
| D0120 |
Periodic oral evaluation - established patient |
7,279 |
7,275 |
$202K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,349 |
1,031 |
$167K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,723 |
1,123 |
$145K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,754 |
2,749 |
$107K |
| D0220 |
Intraoral - periapical first radiographic image |
6,340 |
6,252 |
$102K |
| D0272 |
Bitewings - two radiographic images |
4,307 |
4,296 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,832 |
5,167 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
615 |
486 |
$57K |
| D0240 |
|
2,456 |
1,277 |
$51K |
| D1110 |
Prophylaxis - adult |
976 |
973 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,049 |
1,046 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
655 |
648 |
$28K |
| D9920 |
|
365 |
330 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
235 |
235 |
$7K |
| D1510 |
|
13 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,282 |
1,972 |
$2K |
| D1999 |
|
84 |
75 |
$0.00 |
| D9986 |
|
132 |
127 |
$0.00 |