| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
22,447 |
22,447 |
$786K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,439 |
1,962 |
$693K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,566 |
3,213 |
$579K |
| D0120 |
Periodic oral evaluation - established patient |
21,853 |
21,853 |
$514K |
| D1208 |
Topical application of fluoride, excluding varnish |
25,791 |
25,791 |
$424K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
8,432 |
8,370 |
$274K |
| D0272 |
Bitewings - two radiographic images |
14,255 |
14,255 |
$271K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,746 |
1,014 |
$176K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,074 |
984 |
$171K |
| D0220 |
Intraoral - periapical first radiographic image |
11,820 |
11,759 |
$151K |
| D1351 |
Sealant - per tooth |
4,844 |
1,460 |
$146K |
| D0240 |
|
7,391 |
7,339 |
$142K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,350 |
6,767 |
$136K |
| D1110 |
Prophylaxis - adult |
2,675 |
2,675 |
$134K |
| D0330 |
Panoramic radiographic image |
3,020 |
3,020 |
$133K |
| D9248 |
|
1,364 |
1,362 |
$97K |
| D0140 |
Limited oral evaluation - problem focused |
2,351 |
2,340 |
$90K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,663 |
1,663 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
834 |
612 |
$67K |
| D0274 |
Bitewings - four radiographic images |
1,754 |
1,754 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
751 |
751 |
$30K |
| D9420 |
|
236 |
236 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
226 |
116 |
$18K |
| D2932 |
|
35 |
13 |
$5K |
| D9992 |
|
16 |
16 |
$412.16 |