| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
21,093 |
21,022 |
$591K |
| D1120 |
Prophylaxis - child |
18,220 |
18,162 |
$572K |
| D0120 |
Periodic oral evaluation - established patient |
18,851 |
18,797 |
$507K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,704 |
1,926 |
$245K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,794 |
642 |
$231K |
| D1351 |
Sealant - per tooth |
8,080 |
2,157 |
$225K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,929 |
2,024 |
$201K |
| D1110 |
Prophylaxis - adult |
4,119 |
4,116 |
$167K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,552 |
12,328 |
$138K |
| D0220 |
Intraoral - periapical first radiographic image |
14,323 |
14,169 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,661 |
3,650 |
$98K |
| D0330 |
Panoramic radiographic image |
2,303 |
2,301 |
$92K |
| D0272 |
Bitewings - two radiographic images |
5,480 |
5,462 |
$87K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,168 |
2,950 |
$81K |
| D0274 |
Bitewings - four radiographic images |
3,425 |
3,423 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
860 |
519 |
$65K |
| D9420 |
|
398 |
393 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
1,293 |
1,283 |
$34K |
| D1354 |
|
213 |
98 |
$3K |
| D2332 |
|
21 |
14 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
12 |
$2K |
| D2330 |
|
16 |
12 |
$1K |
| D1999 |
|
27 |
24 |
$262.50 |
| D3120 |
|
28 |
25 |
$30.48 |