| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,447 |
11,087 |
$483K |
| D1206 |
Topical application of fluoride varnish |
12,959 |
12,556 |
$445K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,851 |
2,460 |
$408K |
| D0120 |
Periodic oral evaluation - established patient |
11,357 |
11,043 |
$233K |
| D1351 |
Sealant - per tooth |
6,347 |
2,384 |
$207K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,967 |
1,365 |
$151K |
| D1110 |
Prophylaxis - adult |
1,966 |
1,905 |
$118K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,869 |
3,439 |
$114K |
| D0272 |
Bitewings - two radiographic images |
3,908 |
3,779 |
$94K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
606 |
264 |
$82K |
| D0274 |
Bitewings - four radiographic images |
2,134 |
2,061 |
$72K |
| D0330 |
Panoramic radiographic image |
1,177 |
1,124 |
$71K |
| D7140 |
Extraction, erupted tooth or exposed root |
666 |
367 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
2,913 |
2,814 |
$44K |
| D1354 |
|
1,580 |
425 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
945 |
894 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
897 |
814 |
$30K |
| D1310 |
|
831 |
770 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,245 |
2,175 |
$26K |
| D1330 |
|
687 |
650 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
132 |
102 |
$19K |
| D0240 |
|
571 |
529 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
308 |
295 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
14 |
$5K |
| D3120 |
|
85 |
61 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$378.25 |