| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,488 |
16,477 |
$584K |
| D1351 |
Sealant - per tooth |
8,478 |
3,025 |
$359K |
| D1206 |
Topical application of fluoride varnish |
11,202 |
11,186 |
$286K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
3,250 |
2,137 |
$264K |
| D0120 |
Periodic oral evaluation - established patient |
11,027 |
11,022 |
$258K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,892 |
1,479 |
$248K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,058 |
2,564 |
$236K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,232 |
6,229 |
$148K |
| D2335 |
|
1,255 |
548 |
$119K |
| D0272 |
Bitewings - two radiographic images |
8,904 |
8,902 |
$117K |
| D0220 |
Intraoral - periapical first radiographic image |
11,094 |
11,075 |
$117K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,675 |
1,013 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,795 |
6,788 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,789 |
1,233 |
$70K |
| D1110 |
Prophylaxis - adult |
1,348 |
1,346 |
$59K |
| D0330 |
Panoramic radiographic image |
1,861 |
1,859 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,168 |
10,167 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,169 |
1,169 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
1,848 |
1,830 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,610 |
1,551 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
727 |
727 |
$18K |
| D2394 |
|
180 |
161 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
56 |
$3K |
| D9420 |
|
44 |
44 |
$2K |
| D1354 |
|
71 |
24 |
$1K |
| D9920 |
|
671 |
671 |
$935.88 |
| D0240 |
|
170 |
168 |
$118.76 |
| D1330 |
|
150 |
150 |
$0.00 |
| D9997 |
|
25 |
25 |
$0.00 |
| D1999 |
|
594 |
594 |
$0.00 |