| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,842 |
1,610 |
$725K |
| D1120 |
Prophylaxis - child |
11,394 |
11,249 |
$496K |
| D1206 |
Topical application of fluoride varnish |
16,264 |
16,061 |
$404K |
| D0120 |
Periodic oral evaluation - established patient |
13,246 |
13,081 |
$392K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,994 |
1,579 |
$330K |
| D8670 |
Periodic orthodontic treatment visit |
3,881 |
2,822 |
$288K |
| D1110 |
Prophylaxis - adult |
3,057 |
3,018 |
$184K |
| D0140 |
Limited oral evaluation - problem focused |
3,264 |
3,014 |
$144K |
| D1351 |
Sealant - per tooth |
4,151 |
689 |
$142K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,308 |
2,275 |
$121K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
514 |
129 |
$82K |
| D1330 |
|
8,955 |
8,829 |
$55K |
| D0330 |
Panoramic radiographic image |
1,274 |
1,257 |
$55K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,843 |
2,768 |
$52K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
292 |
101 |
$19K |
| D2940 |
|
325 |
87 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
27 |
$12K |
| D8660 |
|
27 |
27 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$3K |
| D3120 |
|
76 |
37 |
$3K |
| D1510 |
|
21 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
65 |
$594.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$450.00 |