| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,111 |
9,086 |
$399K |
| D1206 |
Topical application of fluoride varnish |
9,861 |
9,831 |
$303K |
| D0120 |
Periodic oral evaluation - established patient |
8,780 |
8,760 |
$218K |
| D1351 |
Sealant - per tooth |
10,102 |
2,418 |
$197K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,631 |
797 |
$162K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,862 |
1,273 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,373 |
9,148 |
$98K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,128 |
2,991 |
$77K |
| D0140 |
Limited oral evaluation - problem focused |
1,260 |
1,249 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
9,557 |
9,482 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
933 |
566 |
$46K |
| D0274 |
Bitewings - four radiographic images |
3,614 |
3,612 |
$43K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
578 |
260 |
$38K |
| D0603 |
|
4,350 |
4,310 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
503 |
368 |
$34K |
| D1110 |
Prophylaxis - adult |
1,061 |
1,016 |
$22K |
| D0272 |
Bitewings - two radiographic images |
2,318 |
2,300 |
$22K |
| D0602 |
|
2,257 |
2,252 |
$21K |
| D9920 |
|
878 |
787 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
788 |
778 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
489 |
479 |
$17K |
| D2932 |
|
101 |
47 |
$15K |
| D0330 |
Panoramic radiographic image |
115 |
115 |
$5K |
| D1353 |
|
440 |
77 |
$4K |
| D1510 |
|
34 |
29 |
$3K |
| D9248 |
|
22 |
15 |
$1K |
| D9310 |
|
13 |
13 |
$260.00 |
| D0601 |
|
12 |
12 |
$120.00 |
| D1330 |
|
94 |
89 |
$0.00 |
| D1310 |
|
133 |
132 |
$0.00 |