| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,079 |
10,996 |
$373K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,066 |
1,191 |
$321K |
| D1206 |
Topical application of fluoride varnish |
11,490 |
11,400 |
$242K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,639 |
1,619 |
$211K |
| D0120 |
Periodic oral evaluation - established patient |
8,381 |
8,309 |
$202K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,441 |
1,356 |
$172K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,940 |
1,199 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,664 |
3,638 |
$104K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,129 |
2,937 |
$90K |
| D1351 |
Sealant - per tooth |
3,492 |
1,273 |
$89K |
| D0272 |
Bitewings - two radiographic images |
4,531 |
4,500 |
$80K |
| D9248 |
|
929 |
885 |
$76K |
| D1354 |
|
7,307 |
1,922 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
3,816 |
3,641 |
$45K |
| D0330 |
Panoramic radiographic image |
933 |
924 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,947 |
1,592 |
$36K |
| D1110 |
Prophylaxis - adult |
786 |
784 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
794 |
784 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
486 |
486 |
$12K |
| D2332 |
|
67 |
39 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
37 |
$4K |
| D0274 |
Bitewings - four radiographic images |
135 |
135 |
$4K |
| D2330 |
|
42 |
25 |
$3K |
| D2331 |
|
33 |
28 |
$2K |
| D1510 |
|
16 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
12 |
$2K |
| D0170 |
|
198 |
195 |
$273.51 |
| D9420 |
|
55 |
42 |
$25.00 |
| D1999 |
|
44 |
43 |
$0.00 |