| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,993 |
5,952 |
$243K |
| D1206 |
Topical application of fluoride varnish |
5,027 |
4,990 |
$155K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,365 |
525 |
$128K |
| D1351 |
Sealant - per tooth |
4,924 |
958 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
4,438 |
4,418 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,647 |
793 |
$100K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,561 |
1,446 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,779 |
2,744 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
648 |
406 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
908 |
906 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
511 |
499 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
382 |
170 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
352 |
205 |
$17K |
| D0603 |
|
1,525 |
1,521 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,924 |
1,889 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
146 |
85 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,429 |
1,398 |
$5K |
| D0602 |
|
485 |
485 |
$4K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
721 |
721 |
$2K |
| D1353 |
|
625 |
140 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
95 |
95 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$730.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$476.00 |
| D0601 |
|
12 |
12 |
$60.00 |
| D9420 |
|
31 |
28 |
$0.00 |