| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,626 |
6,428 |
$266K |
| D1206 |
Topical application of fluoride varnish |
6,616 |
6,416 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
5,639 |
5,471 |
$155K |
| D1351 |
Sealant - per tooth |
2,703 |
1,399 |
$139K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,139 |
654 |
$72K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
409 |
277 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
401 |
274 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,499 |
1,432 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
571 |
326 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,035 |
1,000 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
358 |
215 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,721 |
2,606 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,673 |
2,348 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,455 |
1,419 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
393 |
344 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
186 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
39 |
$623.10 |
| D0330 |
Panoramic radiographic image |
15 |
14 |
$316.40 |