| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
29,365 |
28,843 |
$963K |
| D0120 |
Periodic oral evaluation - established patient |
29,720 |
29,225 |
$704K |
| D1206 |
Topical application of fluoride varnish |
27,791 |
27,281 |
$572K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,246 |
2,089 |
$570K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,123 |
2,291 |
$292K |
| D1351 |
Sealant - per tooth |
9,648 |
3,076 |
$276K |
| D0272 |
Bitewings - two radiographic images |
14,555 |
14,300 |
$250K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,250 |
1,811 |
$235K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
8,313 |
7,975 |
$235K |
| D1110 |
Prophylaxis - adult |
4,838 |
4,785 |
$204K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,128 |
1,046 |
$169K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,351 |
1,854 |
$169K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,153 |
1,678 |
$130K |
| D1354 |
|
16,482 |
3,880 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,805 |
3,724 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,373 |
5,322 |
$92K |
| D0330 |
Panoramic radiographic image |
1,562 |
1,558 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,679 |
2,633 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
5,641 |
5,308 |
$66K |
| D0140 |
Limited oral evaluation - problem focused |
1,446 |
1,403 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,477 |
1,024 |
$27K |
| D2140 |
|
253 |
160 |
$16K |
| D2929 |
|
28 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$3K |
| D2999 |
|
195 |
46 |
$3K |
| D2330 |
|
40 |
29 |
$2K |
| D3120 |
|
468 |
412 |
$419.14 |
| D9420 |
|
833 |
811 |
$305.00 |