| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,617 |
5,385 |
$225K |
| D1206 |
Topical application of fluoride varnish |
5,665 |
5,422 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
4,617 |
4,399 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
909 |
746 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
771 |
658 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,744 |
1,645 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,260 |
1,181 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
832 |
743 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
3,647 |
3,456 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,213 |
3,010 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
286 |
250 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,345 |
1,291 |
$12K |
| D1351 |
Sealant - per tooth |
138 |
79 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
520 |
492 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
25 |
$2K |
| D9310 |
|
102 |
95 |
$2K |
| D1110 |
Prophylaxis - adult |
131 |
125 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
12 |
$895.90 |
| D0330 |
Panoramic radiographic image |
32 |
31 |
$818.20 |
| D0270 |
|
123 |
109 |
$653.40 |
| D1999 |
|
1,242 |
1,022 |
$0.00 |