| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,745 |
11,174 |
$297K |
| D1206 |
Topical application of fluoride varnish |
11,064 |
9,775 |
$245K |
| D0120 |
Periodic oral evaluation - established patient |
11,507 |
8,803 |
$225K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
860 |
310 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,688 |
3,381 |
$102K |
| D0272 |
Bitewings - two radiographic images |
8,191 |
5,613 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
834 |
529 |
$80K |
| D0140 |
Limited oral evaluation - problem focused |
2,339 |
1,648 |
$62K |
| D1351 |
Sealant - per tooth |
3,758 |
420 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,752 |
1,978 |
$43K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
328 |
141 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,917 |
1,529 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
228 |
160 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
581 |
217 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,298 |
2,533 |
$9K |
| D0330 |
Panoramic radiographic image |
131 |
126 |
$8K |
| D1110 |
Prophylaxis - adult |
197 |
187 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
75 |
$2K |