| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,526 |
10,391 |
$260K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,653 |
479 |
$169K |
| D1206 |
Topical application of fluoride varnish |
8,670 |
7,902 |
$163K |
| D0120 |
Periodic oral evaluation - established patient |
6,502 |
5,900 |
$137K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,972 |
4,504 |
$132K |
| D0272 |
Bitewings - two radiographic images |
6,117 |
5,546 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,333 |
805 |
$89K |
| D0140 |
Limited oral evaluation - problem focused |
2,540 |
1,982 |
$82K |
| D7140 |
Extraction, erupted tooth or exposed root |
756 |
416 |
$48K |
| D0330 |
Panoramic radiographic image |
928 |
861 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,585 |
2,331 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,392 |
1,922 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
341 |
147 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,569 |
1,408 |
$16K |
| D0350 |
|
185 |
166 |
$4K |
| D2330 |
|
77 |
38 |
$4K |
| D1351 |
Sealant - per tooth |
90 |
15 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
118 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$2K |
| D9310 |
|
37 |
33 |
$1K |