| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,377 |
15,372 |
$708K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,592 |
1,553 |
$542K |
| D0120 |
Periodic oral evaluation - established patient |
7,525 |
7,523 |
$518K |
| D1310 |
|
9,624 |
9,605 |
$431K |
| D1206 |
Topical application of fluoride varnish |
15,051 |
15,033 |
$298K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,449 |
1,944 |
$292K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,749 |
3,747 |
$251K |
| D7111 |
|
3,682 |
1,930 |
$207K |
| D1351 |
Sealant - per tooth |
5,082 |
1,680 |
$169K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,884 |
3,553 |
$151K |
| D0603 |
|
8,979 |
8,970 |
$131K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,266 |
641 |
$124K |
| D9993 |
|
9,343 |
9,334 |
$124K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,247 |
1,145 |
$120K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,774 |
1,774 |
$119K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,017 |
6,290 |
$117K |
| D0350 |
|
6,851 |
2,991 |
$68K |
| D2390 |
|
611 |
215 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
5,314 |
5,253 |
$62K |
| D9430 |
|
1,361 |
1,328 |
$43K |
| D0274 |
Bitewings - four radiographic images |
859 |
857 |
$18K |
| D0330 |
Panoramic radiographic image |
584 |
584 |
$17K |
| D0601 |
|
250 |
250 |
$4K |
| D1354 |
|
229 |
132 |
$4K |
| D0272 |
Bitewings - two radiographic images |
255 |
254 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
238 |
$3K |
| D2330 |
|
15 |
12 |
$1K |