| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,379 |
6,378 |
$353K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,837 |
870 |
$249K |
| D1351 |
Sealant - per tooth |
9,073 |
2,445 |
$221K |
| D0120 |
Periodic oral evaluation - established patient |
5,602 |
5,602 |
$189K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,488 |
1,676 |
$175K |
| D1206 |
Topical application of fluoride varnish |
4,982 |
4,981 |
$154K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,202 |
941 |
$126K |
| D0272 |
Bitewings - two radiographic images |
4,758 |
4,755 |
$61K |
| D9999 |
Unspecified adjunctive procedure, by report |
84 |
84 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,694 |
1,694 |
$51K |
| D2332 |
|
485 |
276 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
699 |
465 |
$44K |
| D0240 |
|
3,361 |
3,360 |
$44K |
| D9920 |
|
1,420 |
1,333 |
$35K |
| D0603 |
|
3,581 |
3,579 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
737 |
736 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
347 |
214 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
525 |
511 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,159 |
2,155 |
$15K |
| D1110 |
Prophylaxis - adult |
229 |
229 |
$13K |
| D0330 |
Panoramic radiographic image |
220 |
220 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
162 |
103 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,571 |
1,571 |
$8K |
| D0274 |
Bitewings - four radiographic images |
420 |
420 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
83 |
$5K |
| D2394 |
|
38 |
37 |
$4K |
| D0602 |
|
338 |
338 |
$3K |
| D0601 |
|
26 |
26 |
$260.00 |