| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,242 |
6,225 |
$247K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,580 |
2,115 |
$239K |
| D0120 |
Periodic oral evaluation - established patient |
6,446 |
6,434 |
$213K |
| D1206 |
Topical application of fluoride varnish |
4,320 |
4,302 |
$103K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,761 |
1,204 |
$88K |
| D1351 |
Sealant - per tooth |
4,011 |
1,125 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,678 |
2,678 |
$42K |
| D0272 |
Bitewings - two radiographic images |
3,197 |
3,194 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,743 |
1,555 |
$31K |
| D1110 |
Prophylaxis - adult |
980 |
976 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
735 |
721 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,760 |
3,718 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
314 |
235 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
630 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,835 |
2,812 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
122 |
103 |
$10K |
| D0274 |
Bitewings - four radiographic images |
555 |
553 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
70 |
60 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
66 |
55 |
$4K |
| D1999 |
|
668 |
599 |
$0.00 |
| D0603 |
|
150 |
150 |
$0.00 |
| D1330 |
|
349 |
349 |
$0.00 |
| D0601 |
|
49 |
49 |
$0.00 |