| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,127 |
5,104 |
$215K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,163 |
2,096 |
$146K |
| D1206 |
Topical application of fluoride varnish |
5,075 |
5,051 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
4,266 |
4,246 |
$122K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
880 |
801 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,204 |
976 |
$77K |
| D1351 |
Sealant - per tooth |
1,353 |
631 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,003 |
784 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,279 |
2,780 |
$29K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
429 |
405 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
619 |
517 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
942 |
938 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,291 |
3,243 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,423 |
1,415 |
$15K |
| D9310 |
|
589 |
584 |
$9K |
| D0330 |
Panoramic radiographic image |
332 |
332 |
$9K |
| D1354 |
|
362 |
190 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
375 |
370 |
$7K |
| D0274 |
Bitewings - four radiographic images |
265 |
261 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D1510 |
|
12 |
12 |
$847.20 |
| D2330 |
|
12 |
12 |
$573.98 |