| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,953 |
11,951 |
$499K |
| D0120 |
Periodic oral evaluation - established patient |
13,789 |
13,786 |
$372K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,506 |
765 |
$279K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,861 |
2,096 |
$271K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,313 |
13,311 |
$182K |
| D1351 |
Sealant - per tooth |
4,524 |
1,859 |
$180K |
| D1110 |
Prophylaxis - adult |
2,613 |
2,613 |
$135K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,084 |
1,056 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,512 |
938 |
$73K |
| D0330 |
Panoramic radiographic image |
1,928 |
1,928 |
$67K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
774 |
351 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
4,329 |
4,320 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,125 |
2,928 |
$55K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,878 |
1,829 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,030 |
2,030 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,158 |
1,158 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
477 |
477 |
$14K |
| D1354 |
|
456 |
207 |
$13K |
| D9110 |
|
350 |
349 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
307 |
307 |
$7K |
| D2335 |
|
27 |
12 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$348.00 |