| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
14,140 |
13,751 |
$467K |
| D0120 |
Periodic oral evaluation - established patient |
12,661 |
12,292 |
$305K |
| D1206 |
Topical application of fluoride varnish |
14,058 |
13,673 |
$294K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,815 |
1,115 |
$289K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,101 |
1,623 |
$211K |
| D1351 |
Sealant - per tooth |
4,099 |
1,309 |
$119K |
| D9248 |
|
1,253 |
1,203 |
$106K |
| D0272 |
Bitewings - two radiographic images |
4,975 |
4,843 |
$85K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,463 |
755 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,258 |
903 |
$73K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,294 |
2,213 |
$66K |
| D0330 |
Panoramic radiographic image |
1,424 |
1,375 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,792 |
1,767 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
2,933 |
2,789 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
472 |
270 |
$34K |
| D1354 |
|
3,337 |
989 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,606 |
987 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
555 |
528 |
$12K |
| D2332 |
|
102 |
55 |
$6K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$293.15 |
| D0270 |
|
20 |
20 |
$152.10 |
| D9420 |
|
12 |
12 |
$0.00 |