| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,122 |
9,111 |
$406K |
| D1206 |
Topical application of fluoride varnish |
8,972 |
8,961 |
$280K |
| D9999 |
Unspecified adjunctive procedure, by report |
534 |
520 |
$214K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,097 |
1,869 |
$210K |
| D0120 |
Periodic oral evaluation - established patient |
7,713 |
7,702 |
$203K |
| D1351 |
Sealant - per tooth |
7,242 |
1,982 |
$150K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,310 |
3,167 |
$82K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,549 |
896 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,438 |
943 |
$76K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
529 |
342 |
$46K |
| D9248 |
|
258 |
188 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,780 |
1,778 |
$43K |
| D0272 |
Bitewings - two radiographic images |
3,619 |
3,609 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
680 |
676 |
$29K |
| D0240 |
|
1,571 |
1,563 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
487 |
310 |
$28K |
| D0274 |
Bitewings - four radiographic images |
892 |
892 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,994 |
1,983 |
$11K |
| D0603 |
|
1,195 |
1,190 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,420 |
1,412 |
$10K |
| D0602 |
|
693 |
693 |
$6K |
| D1110 |
Prophylaxis - adult |
132 |
132 |
$6K |
| D0601 |
|
541 |
540 |
$5K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
349 |
349 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$1K |
| D9920 |
|
16 |
15 |
$402.72 |