| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,323 |
5,213 |
$170K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,554 |
648 |
$169K |
| D9248 |
|
1,540 |
1,467 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,700 |
911 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
5,161 |
5,059 |
$121K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,252 |
5,141 |
$104K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,198 |
490 |
$93K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,161 |
600 |
$65K |
| D0272 |
Bitewings - two radiographic images |
3,019 |
2,958 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,257 |
1,223 |
$34K |
| D1351 |
Sealant - per tooth |
1,021 |
270 |
$31K |
| D1110 |
Prophylaxis - adult |
715 |
702 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,173 |
1,125 |
$25K |
| D0330 |
Panoramic radiographic image |
556 |
550 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
590 |
559 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,280 |
1,243 |
$15K |
| D9110 |
|
255 |
250 |
$11K |
| D1206 |
Topical application of fluoride varnish |
534 |
523 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
254 |
205 |
$2K |
| D1330 |
|
4,737 |
4,621 |
$26.00 |