| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,868 |
12,864 |
$457K |
| D1351 |
Sealant - per tooth |
8,484 |
2,809 |
$336K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,244 |
1,494 |
$224K |
| D0120 |
Periodic oral evaluation - established patient |
8,659 |
8,658 |
$206K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,255 |
1,979 |
$202K |
| D1206 |
Topical application of fluoride varnish |
8,014 |
8,014 |
$199K |
| D0274 |
Bitewings - four radiographic images |
7,107 |
7,105 |
$155K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,805 |
1,264 |
$127K |
| D0220 |
Intraoral - periapical first radiographic image |
11,098 |
11,063 |
$124K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,404 |
1,697 |
$113K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,245 |
4,245 |
$104K |
| D0330 |
Panoramic radiographic image |
2,804 |
2,804 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,197 |
9,179 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,389 |
6,388 |
$74K |
| D1110 |
Prophylaxis - adult |
1,484 |
1,484 |
$70K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,516 |
1,516 |
$37K |
| D1354 |
|
1,398 |
422 |
$32K |
| D9310 |
|
504 |
504 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
2,488 |
2,483 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
603 |
478 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
631 |
631 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
210 |
195 |
$5K |
| D0272 |
Bitewings - two radiographic images |
387 |
387 |
$5K |
| D1320 |
|
556 |
556 |
$4K |
| D2332 |
|
49 |
40 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
43 |
$3K |
| D9990 |
|
72 |
61 |
$3K |
| D0160 |
|
104 |
104 |
$2K |
| D9920 |
|
871 |
741 |
$615.06 |
| D0603 |
|
260 |
259 |
$170.00 |
| D0601 |
|
124 |
123 |
$86.00 |
| D0602 |
|
30 |
30 |
$30.00 |
| D1999 |
|
70 |
55 |
$0.00 |