| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
7,036 |
7,034 |
$395K |
| D0120 |
Periodic oral evaluation - established patient |
11,222 |
11,220 |
$318K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,109 |
1,468 |
$169K |
| D1120 |
Prophylaxis - child |
3,903 |
3,903 |
$167K |
| D0274 |
Bitewings - four radiographic images |
5,849 |
5,848 |
$155K |
| D1351 |
Sealant - per tooth |
3,125 |
1,125 |
$139K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
932 |
761 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,199 |
5,198 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
3,811 |
3,770 |
$48K |
| D0272 |
Bitewings - two radiographic images |
2,866 |
2,866 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
768 |
577 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
524 |
524 |
$30K |
| D2394 |
|
199 |
175 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
223 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
125 |
95 |
$13K |
| D1206 |
Topical application of fluoride varnish |
262 |
262 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
455 |
455 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
96 |
68 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$6K |
| D2335 |
|
38 |
28 |
$5K |
| D0240 |
|
292 |
291 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
461 |
460 |
$3K |
| D4341 |
|
51 |
25 |
$3K |
| D2954 |
|
14 |
12 |
$2K |
| D1999 |
|
29 |
29 |
$1K |
| D7111 |
|
20 |
13 |
$601.00 |
| D0273 |
|
24 |
24 |
$435.24 |
| D0603 |
|
255 |
255 |
$255.00 |
| D0602 |
|
85 |
85 |
$85.00 |
| D0601 |
|
26 |
26 |
$26.00 |