| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,780 |
13,693 |
$434K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,449 |
6,408 |
$224K |
| D1206 |
Topical application of fluoride varnish |
10,300 |
10,222 |
$187K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,135 |
13,205 |
$162K |
| D0220 |
Intraoral - periapical first radiographic image |
14,059 |
13,917 |
$158K |
| D0274 |
Bitewings - four radiographic images |
5,323 |
5,307 |
$157K |
| D0120 |
Periodic oral evaluation - established patient |
6,389 |
6,363 |
$144K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,006 |
435 |
$115K |
| D0272 |
Bitewings - two radiographic images |
4,974 |
4,954 |
$101K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,363 |
3,226 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,145 |
773 |
$84K |
| D1351 |
Sealant - per tooth |
3,044 |
964 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,291 |
891 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,503 |
3,497 |
$63K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
421 |
163 |
$29K |
| D0330 |
Panoramic radiographic image |
464 |
464 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
306 |
183 |
$20K |
| D8660 |
|
171 |
170 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
239 |
$7K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D9248 |
|
41 |
40 |
$905.57 |