| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
17,873 |
17,872 |
$761K |
| D0120 |
Periodic oral evaluation - established patient |
18,569 |
18,567 |
$500K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,896 |
3,439 |
$388K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,610 |
947 |
$369K |
| D1206 |
Topical application of fluoride varnish |
10,376 |
10,372 |
$298K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,679 |
3,251 |
$239K |
| D1351 |
Sealant - per tooth |
3,099 |
2,384 |
$234K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,392 |
1,892 |
$167K |
| D1110 |
Prophylaxis - adult |
3,063 |
3,063 |
$162K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,211 |
11,210 |
$156K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
936 |
651 |
$124K |
| D0272 |
Bitewings - two radiographic images |
6,721 |
6,721 |
$106K |
| D0330 |
Panoramic radiographic image |
2,630 |
2,630 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,337 |
2,337 |
$69K |
| D0274 |
Bitewings - four radiographic images |
1,947 |
1,947 |
$52K |
| D9420 |
|
463 |
461 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,316 |
2,294 |
$29K |
| D9110 |
|
604 |
601 |
$15K |
| D1354 |
|
455 |
225 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
399 |
366 |
$9K |
| D9310 |
|
97 |
97 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
71 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
360 |
358 |
$5K |
| D9430 |
|
206 |
204 |
$3K |
| D2330 |
|
16 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$210.82 |
| D1999 |
|
1,091 |
1,054 |
$0.00 |