| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,923 |
12,835 |
$289K |
| D0120 |
Periodic oral evaluation - established patient |
11,061 |
10,987 |
$215K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,131 |
1,630 |
$177K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,815 |
8,740 |
$129K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,640 |
1,067 |
$113K |
| D1206 |
Topical application of fluoride varnish |
5,092 |
5,067 |
$102K |
| D1351 |
Sealant - per tooth |
3,981 |
1,122 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,417 |
2,221 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,103 |
731 |
$72K |
| D0272 |
Bitewings - two radiographic images |
5,601 |
5,570 |
$65K |
| D1110 |
Prophylaxis - adult |
1,493 |
1,484 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,802 |
1,791 |
$48K |
| D0330 |
Panoramic radiographic image |
812 |
811 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
336 |
133 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
343 |
134 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
688 |
672 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
179 |
127 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,655 |
1,638 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
151 |
82 |
$8K |
| D0274 |
Bitewings - four radiographic images |
387 |
385 |
$7K |
| D2160 |
|
69 |
53 |
$4K |
| D2332 |
|
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
88 |
$445.00 |