| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,046 |
4,927 |
$256K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,494 |
656 |
$163K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
804 |
262 |
$154K |
| D1206 |
Topical application of fluoride varnish |
5,783 |
5,658 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
4,890 |
4,777 |
$141K |
| D7140 |
Extraction, erupted tooth or exposed root |
845 |
399 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
928 |
896 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,069 |
1,031 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,414 |
1,389 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
468 |
258 |
$40K |
| D1110 |
Prophylaxis - adult |
540 |
532 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,636 |
1,576 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,433 |
889 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
179 |
65 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
794 |
711 |
$16K |
| D1351 |
Sealant - per tooth |
374 |
102 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
106 |
38 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
208 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
27 |
$5K |
| D0330 |
Panoramic radiographic image |
29 |
26 |
$2K |
| D1999 |
|
288 |
277 |
$0.00 |
| D1330 |
|
310 |
307 |
$0.00 |