| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,763 |
11,763 |
$489K |
| D0120 |
Periodic oral evaluation - established patient |
8,968 |
8,968 |
$242K |
| D1206 |
Topical application of fluoride varnish |
8,174 |
8,174 |
$200K |
| D0272 |
Bitewings - two radiographic images |
4,336 |
4,336 |
$69K |
| D1110 |
Prophylaxis - adult |
1,285 |
1,285 |
$69K |
| D1351 |
Sealant - per tooth |
1,502 |
556 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
907 |
646 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,128 |
2,128 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
868 |
563 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,871 |
2,871 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
317 |
184 |
$36K |
| D0330 |
Panoramic radiographic image |
791 |
791 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
424 |
313 |
$22K |
| D0274 |
Bitewings - four radiographic images |
371 |
371 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
473 |
464 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
80 |
52 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
444 |
442 |
$6K |
| D7962 |
|
24 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
297 |
$4K |
| D1354 |
|
55 |
28 |
$720.00 |
| D0240 |
|
24 |
24 |
$369.92 |
| D1999 |
|
17 |
17 |
$0.00 |