| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,039 |
13,034 |
$529K |
| D0120 |
Periodic oral evaluation - established patient |
13,567 |
13,564 |
$369K |
| D1351 |
Sealant - per tooth |
4,264 |
1,902 |
$241K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,583 |
1,735 |
$213K |
| D1206 |
Topical application of fluoride varnish |
7,253 |
7,237 |
$197K |
| D1110 |
Prophylaxis - adult |
2,386 |
2,386 |
$128K |
| D0220 |
Intraoral - periapical first radiographic image |
9,574 |
9,532 |
$122K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,223 |
8,220 |
$110K |
| D0272 |
Bitewings - two radiographic images |
6,854 |
6,851 |
$109K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,171 |
8,161 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,733 |
1,731 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
639 |
495 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,193 |
1,121 |
$24K |
| D0274 |
Bitewings - four radiographic images |
684 |
684 |
$18K |
| D0330 |
Panoramic radiographic image |
480 |
480 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
113 |
93 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
58 |
51 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
65 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
16 |
$2K |
| D9990 |
|
97 |
94 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
159 |
158 |
$2K |
| D0240 |
|
132 |
130 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$430.12 |