| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
22,840 |
20,189 |
$565K |
| D1206 |
Topical application of fluoride varnish |
22,855 |
20,200 |
$425K |
| D0120 |
Periodic oral evaluation - established patient |
19,123 |
16,915 |
$418K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,377 |
856 |
$410K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,096 |
982 |
$194K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,195 |
3,706 |
$136K |
| D0272 |
Bitewings - two radiographic images |
10,138 |
9,054 |
$119K |
| D1354 |
|
2,334 |
643 |
$50K |
| D0330 |
Panoramic radiographic image |
893 |
796 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
583 |
393 |
$31K |
| D1351 |
Sealant - per tooth |
1,390 |
404 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
808 |
714 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
3,372 |
3,029 |
$19K |
| D0274 |
Bitewings - four radiographic images |
588 |
498 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
717 |
665 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,558 |
415 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
64 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
43 |
28 |
$3K |
| D0240 |
|
78 |
61 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
53 |
$924.00 |