| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,320 |
15,320 |
$443K |
| D0120 |
Periodic oral evaluation - established patient |
13,995 |
13,995 |
$407K |
| D2161 |
|
5,247 |
1,817 |
$406K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,277 |
1,298 |
$263K |
| D0240 |
|
12,170 |
12,170 |
$259K |
| D0330 |
Panoramic radiographic image |
4,624 |
4,622 |
$247K |
| D0220 |
Intraoral - periapical first radiographic image |
19,001 |
18,902 |
$227K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,241 |
1,280 |
$218K |
| D2160 |
|
2,969 |
1,307 |
$207K |
| D0274 |
Bitewings - four radiographic images |
6,522 |
6,522 |
$199K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,249 |
295 |
$198K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,665 |
15,665 |
$185K |
| D0272 |
Bitewings - two radiographic images |
9,415 |
9,414 |
$184K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,905 |
8,733 |
$123K |
| D1351 |
Sealant - per tooth |
4,318 |
1,659 |
$122K |
| D2394 |
|
601 |
196 |
$116K |
| D1110 |
Prophylaxis - adult |
2,741 |
2,740 |
$111K |
| D1206 |
Topical application of fluoride varnish |
2,435 |
2,435 |
$59K |
| D2335 |
|
444 |
248 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
716 |
446 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
927 |
927 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
918 |
912 |
$27K |
| D2332 |
|
121 |
67 |
$10K |
| D2140 |
|
123 |
69 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
12 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
41 |
25 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$687.96 |