| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,872 |
13,799 |
$589K |
| D0120 |
Periodic oral evaluation - established patient |
11,258 |
11,205 |
$317K |
| D1206 |
Topical application of fluoride varnish |
14,982 |
14,909 |
$298K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,459 |
1,399 |
$230K |
| D1351 |
Sealant - per tooth |
4,013 |
763 |
$139K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,676 |
3,654 |
$114K |
| D0220 |
Intraoral - periapical first radiographic image |
7,887 |
7,829 |
$90K |
| D0272 |
Bitewings - two radiographic images |
4,222 |
4,207 |
$76K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,161 |
7,471 |
$75K |
| D0330 |
Panoramic radiographic image |
780 |
770 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,128 |
1,983 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
313 |
186 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,442 |
1,436 |
$31K |
| D1110 |
Prophylaxis - adult |
483 |
482 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
136 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
154 |
104 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
178 |
125 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
376 |
370 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
41 |
$5K |
| D9110 |
|
165 |
164 |
$4K |
| D0240 |
|
72 |
72 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$464.00 |