| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,714 |
16,569 |
$553K |
| D1206 |
Topical application of fluoride varnish |
19,721 |
19,551 |
$412K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,114 |
934 |
$346K |
| D0120 |
Periodic oral evaluation - established patient |
13,800 |
13,708 |
$334K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,214 |
5,146 |
$148K |
| D1110 |
Prophylaxis - adult |
3,471 |
3,438 |
$146K |
| D0330 |
Panoramic radiographic image |
2,729 |
2,706 |
$115K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,554 |
776 |
$96K |
| D0272 |
Bitewings - two radiographic images |
5,087 |
5,030 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,110 |
867 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
6,743 |
6,487 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,304 |
3,447 |
$72K |
| D0274 |
Bitewings - four radiographic images |
2,549 |
2,524 |
$66K |
| D1351 |
Sealant - per tooth |
2,079 |
494 |
$61K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,214 |
2,140 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
785 |
646 |
$46K |
| D9248 |
|
414 |
398 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
1,537 |
1,481 |
$34K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,312 |
1,297 |
$31K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
125 |
76 |
$10K |