| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,002 |
9,851 |
$418K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,620 |
1,332 |
$310K |
| D1206 |
Topical application of fluoride varnish |
11,770 |
11,595 |
$289K |
| D0120 |
Periodic oral evaluation - established patient |
8,994 |
8,859 |
$258K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,611 |
706 |
$243K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,534 |
916 |
$154K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,769 |
2,735 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
951 |
644 |
$88K |
| D1110 |
Prophylaxis - adult |
1,323 |
1,306 |
$76K |
| D0272 |
Bitewings - two radiographic images |
3,360 |
3,303 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,782 |
2,505 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
925 |
891 |
$39K |
| D1330 |
|
5,227 |
5,169 |
$31K |
| D1351 |
Sealant - per tooth |
701 |
157 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
377 |
222 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,015 |
1,002 |
$22K |
| D0330 |
Panoramic radiographic image |
388 |
379 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,055 |
1,038 |
$9K |
| D3120 |
|
195 |
102 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$174.00 |