| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,719 |
7,716 |
$437K |
| D1206 |
Topical application of fluoride varnish |
7,435 |
7,435 |
$296K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,328 |
1,168 |
$248K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,367 |
364 |
$202K |
| D0120 |
Periodic oral evaluation - established patient |
4,317 |
4,317 |
$165K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,235 |
517 |
$73K |
| D0274 |
Bitewings - four radiographic images |
1,353 |
1,351 |
$52K |
| D1351 |
Sealant - per tooth |
819 |
343 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,791 |
1,791 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
839 |
839 |
$32K |
| D0330 |
Panoramic radiographic image |
456 |
456 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
215 |
76 |
$24K |
| D1354 |
|
1,209 |
382 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
148 |
99 |
$20K |
| D0240 |
|
502 |
464 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
41 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
314 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
286 |
286 |
$5K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$2K |
| D2330 |
|
23 |
12 |
$2K |
| D9420 |
|
12 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$800.00 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$407.20 |
| D1999 |
|
12 |
12 |
$0.00 |