| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,244 |
10,103 |
$414K |
| D1351 |
Sealant - per tooth |
4,897 |
2,097 |
$298K |
| D1206 |
Topical application of fluoride varnish |
9,976 |
9,836 |
$256K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,292 |
2,453 |
$226K |
| D0120 |
Periodic oral evaluation - established patient |
6,534 |
6,451 |
$181K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,417 |
2,179 |
$141K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,207 |
4,135 |
$99K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,410 |
1,128 |
$77K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
777 |
689 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,265 |
2,229 |
$41K |
| D0272 |
Bitewings - two radiographic images |
3,787 |
3,720 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
868 |
724 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
5,057 |
4,813 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,318 |
4,095 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,182 |
1,149 |
$20K |
| D9310 |
|
439 |
425 |
$7K |
| D9110 |
|
126 |
125 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
15 |
$2K |
| D0270 |
|
233 |
232 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
15 |
$895.90 |