| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,534 |
12,897 |
$702K |
| D1206 |
Topical application of fluoride varnish |
13,807 |
13,097 |
$673K |
| D0120 |
Periodic oral evaluation - established patient |
12,389 |
11,782 |
$377K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,428 |
2,604 |
$188K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,145 |
2,166 |
$185K |
| D0220 |
Intraoral - periapical first radiographic image |
8,843 |
8,205 |
$147K |
| D0272 |
Bitewings - two radiographic images |
6,777 |
6,344 |
$129K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,071 |
440 |
$81K |
| D9248 |
|
1,033 |
872 |
$79K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,475 |
9,378 |
$65K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,309 |
456 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,832 |
3,416 |
$64K |
| D1110 |
Prophylaxis - adult |
1,319 |
1,263 |
$59K |
| D0274 |
Bitewings - four radiographic images |
957 |
901 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
334 |
155 |
$12K |
| D1351 |
Sealant - per tooth |
431 |
146 |
$9K |
| D0999 |
Unspecified diagnostic procedure, by report |
268 |
268 |
$8K |
| D9999 |
Unspecified adjunctive procedure, by report |
311 |
311 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
223 |
$7K |
| D9210 |
|
608 |
541 |
$6K |
| D0170 |
|
147 |
128 |
$2K |
| D1999 |
|
41 |
41 |
$615.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$266.50 |