| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,110 |
5,901 |
$245K |
| D1206 |
Topical application of fluoride varnish |
6,093 |
5,879 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
4,948 |
4,769 |
$136K |
| D1351 |
Sealant - per tooth |
1,824 |
1,013 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,692 |
1,312 |
$111K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,287 |
1,133 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
905 |
734 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,295 |
1,233 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
551 |
439 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,600 |
1,539 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,424 |
1,368 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,562 |
1,316 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,829 |
1,736 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
82 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
339 |
318 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
69 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
25 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
58 |
$1K |
| D1354 |
|
18 |
12 |
$579.15 |
| D9310 |
|
19 |
17 |
$307.80 |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$275.00 |
| D1999 |
|
490 |
398 |
$0.00 |