| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,137 |
12,889 |
$677K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,332 |
541 |
$465K |
| D0120 |
Periodic oral evaluation - established patient |
14,998 |
14,677 |
$428K |
| D1206 |
Topical application of fluoride varnish |
15,593 |
15,306 |
$410K |
| D1110 |
Prophylaxis - adult |
3,588 |
3,501 |
$217K |
| D0274 |
Bitewings - four radiographic images |
5,014 |
4,914 |
$215K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,438 |
629 |
$160K |
| D1351 |
Sealant - per tooth |
3,806 |
1,132 |
$154K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,461 |
699 |
$143K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,822 |
1,784 |
$100K |
| D0220 |
Intraoral - periapical first radiographic image |
4,368 |
4,232 |
$84K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
868 |
306 |
$81K |
| D0272 |
Bitewings - two radiographic images |
2,305 |
2,270 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
1,434 |
1,402 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,805 |
2,169 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,193 |
2,092 |
$45K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
361 |
161 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
99 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
277 |
269 |
$19K |
| D7961 |
|
53 |
49 |
$18K |
| D2934 |
|
25 |
13 |
$4K |
| D1510 |
|
19 |
15 |
$4K |
| D1354 |
|
171 |
48 |
$3K |
| D3120 |
|
46 |
26 |
$2K |
| D1999 |
|
1,036 |
972 |
$0.00 |
| D9986 |
|
322 |
318 |
$0.00 |