| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
14,060 |
13,309 |
$776K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,726 |
1,361 |
$299K |
| D1206 |
Topical application of fluoride varnish |
14,225 |
13,445 |
$234K |
| D0120 |
Periodic oral evaluation - established patient |
9,213 |
8,598 |
$224K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,915 |
1,931 |
$192K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,135 |
4,968 |
$156K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,409 |
3,169 |
$119K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,065 |
1,358 |
$108K |
| D0330 |
Panoramic radiographic image |
1,399 |
1,313 |
$80K |
| D0272 |
Bitewings - two radiographic images |
3,351 |
3,190 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
976 |
573 |
$64K |
| D0140 |
Limited oral evaluation - problem focused |
1,363 |
1,282 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,045 |
1,864 |
$50K |
| D1351 |
Sealant - per tooth |
2,309 |
639 |
$50K |
| D1110 |
Prophylaxis - adult |
790 |
743 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,226 |
2,973 |
$36K |
| D0274 |
Bitewings - four radiographic images |
735 |
678 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
389 |
360 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
160 |
108 |
$10K |
| D9248 |
|
68 |
66 |
$3K |
| D2330 |
|
32 |
25 |
$2K |
| D1354 |
|
98 |
51 |
$959.10 |
| D9986 |
|
43 |
42 |
$120.00 |
| D0603 |
|
40 |
40 |
$0.00 |