| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,864 |
12,424 |
$459K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,702 |
1,456 |
$372K |
| D1351 |
Sealant - per tooth |
11,498 |
2,288 |
$346K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,531 |
574 |
$342K |
| D1206 |
Topical application of fluoride varnish |
14,436 |
13,385 |
$313K |
| D1310 |
|
6,937 |
6,687 |
$275K |
| D0120 |
Periodic oral evaluation - established patient |
9,073 |
8,851 |
$244K |
| D0272 |
Bitewings - two radiographic images |
7,059 |
6,852 |
$168K |
| D1330 |
|
6,919 |
6,670 |
$164K |
| D0603 |
|
13,987 |
13,545 |
$149K |
| D0425 |
|
2,662 |
2,567 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,991 |
2,826 |
$104K |
| D0240 |
|
4,590 |
2,333 |
$96K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,713 |
2,472 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,025 |
615 |
$78K |
| D7140 |
Extraction, erupted tooth or exposed root |
974 |
570 |
$77K |
| D0330 |
Panoramic radiographic image |
1,104 |
1,078 |
$67K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,687 |
1,648 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
1,358 |
1,292 |
$48K |
| D1110 |
Prophylaxis - adult |
921 |
906 |
$48K |
| D9630 |
|
2,809 |
2,690 |
$45K |
| D1353 |
|
1,075 |
414 |
$32K |
| D0274 |
Bitewings - four radiographic images |
737 |
728 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
891 |
808 |
$15K |
| D2332 |
|
70 |
41 |
$9K |
| D2929 |
|
35 |
12 |
$7K |
| D7961 |
|
28 |
28 |
$7K |
| D1354 |
|
272 |
75 |
$7K |
| D1320 |
|
144 |
139 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
93 |
$2K |
| D9920 |
|
41 |
37 |
$2K |
| D2330 |
|
17 |
13 |
$1K |
| D1999 |
|
1,023 |
946 |
$1K |