| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
18,190 |
17,925 |
$800K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,381 |
2,004 |
$696K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,094 |
2,681 |
$499K |
| D1206 |
Topical application of fluoride varnish |
19,789 |
19,500 |
$486K |
| D0120 |
Periodic oral evaluation - established patient |
14,658 |
14,460 |
$435K |
| D9248 |
|
1,618 |
1,562 |
$296K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,311 |
5,213 |
$274K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,654 |
1,912 |
$250K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,035 |
1,189 |
$223K |
| D1351 |
Sealant - per tooth |
6,344 |
1,821 |
$216K |
| D0272 |
Bitewings - two radiographic images |
6,690 |
6,592 |
$102K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,927 |
4,665 |
$91K |
| D1110 |
Prophylaxis - adult |
1,002 |
992 |
$59K |
| D1330 |
|
9,567 |
9,398 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
880 |
864 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
3,151 |
3,068 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,031 |
1,016 |
$23K |
| D0330 |
Panoramic radiographic image |
371 |
364 |
$16K |
| D0240 |
|
1,038 |
1,017 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
701 |
688 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
145 |
90 |
$8K |
| D2933 |
|
30 |
12 |
$2K |
| D7111 |
|
44 |
28 |
$1K |
| D3120 |
|
28 |
24 |
$945.00 |