| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,001 |
14,560 |
$614K |
| D0120 |
Periodic oral evaluation - established patient |
12,283 |
11,904 |
$345K |
| D1206 |
Topical application of fluoride varnish |
13,165 |
12,856 |
$345K |
| D1351 |
Sealant - per tooth |
3,190 |
2,072 |
$269K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,043 |
2,539 |
$219K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,898 |
1,796 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,461 |
3,306 |
$79K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,284 |
1,145 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,635 |
1,440 |
$77K |
| D0274 |
Bitewings - four radiographic images |
3,032 |
2,895 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
8,734 |
8,380 |
$53K |
| D0272 |
Bitewings - two radiographic images |
4,533 |
4,384 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,760 |
1,625 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
2,272 |
2,170 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,515 |
7,225 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
156 |
144 |
$12K |
| D1110 |
Prophylaxis - adult |
309 |
281 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
37 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
24 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
79 |
73 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$376.40 |
| D9310 |
|
20 |
16 |
$273.60 |
| D0270 |
|
30 |
27 |
$162.40 |
| D1999 |
|
947 |
664 |
$0.00 |