| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
24,201 |
15,912 |
$529K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,208 |
1,757 |
$488K |
| D0120 |
Periodic oral evaluation - established patient |
26,991 |
17,885 |
$426K |
| D1206 |
Topical application of fluoride varnish |
26,412 |
17,362 |
$354K |
| D0330 |
Panoramic radiographic image |
6,794 |
4,509 |
$182K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,060 |
1,961 |
$161K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,638 |
882 |
$153K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,193 |
1,557 |
$149K |
| D1351 |
Sealant - per tooth |
8,049 |
1,801 |
$149K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,465 |
4,806 |
$138K |
| D1110 |
Prophylaxis - adult |
4,671 |
3,004 |
$128K |
| D0272 |
Bitewings - two radiographic images |
9,626 |
6,151 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,856 |
2,911 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,300 |
794 |
$81K |
| D1354 |
|
11,757 |
2,104 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,685 |
1,709 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
4,580 |
3,194 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
2,619 |
1,732 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,972 |
1,453 |
$35K |
| D9248 |
|
342 |
202 |
$16K |
| D2929 |
|
31 |
13 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$1K |
| D2330 |
|
16 |
13 |
$951.60 |