| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,206 |
6,286 |
$191K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,348 |
257 |
$171K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,642 |
864 |
$171K |
| D1206 |
Topical application of fluoride varnish |
6,510 |
5,726 |
$146K |
| D0120 |
Periodic oral evaluation - established patient |
5,568 |
4,805 |
$135K |
| D0272 |
Bitewings - two radiographic images |
2,921 |
2,581 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,433 |
1,282 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
511 |
324 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,773 |
1,129 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
516 |
189 |
$31K |
| D0330 |
Panoramic radiographic image |
430 |
350 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
250 |
201 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
266 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
52 |
$969.63 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
52 |
$899.53 |
| D9999 |
Unspecified adjunctive procedure, by report |
82 |
59 |
$0.15 |