| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,409 |
7,405 |
$266K |
| D0120 |
Periodic oral evaluation - established patient |
7,611 |
7,609 |
$184K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,655 |
1,936 |
$150K |
| D1351 |
Sealant - per tooth |
3,050 |
1,454 |
$149K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,926 |
8,918 |
$106K |
| D1110 |
Prophylaxis - adult |
1,918 |
1,918 |
$91K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
952 |
768 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,644 |
1,300 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,575 |
1,220 |
$62K |
| D0272 |
Bitewings - two radiographic images |
4,012 |
4,011 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
3,737 |
3,688 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,717 |
1,717 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,707 |
2,605 |
$24K |
| D0274 |
Bitewings - four radiographic images |
976 |
976 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
324 |
260 |
$19K |
| D0330 |
Panoramic radiographic image |
469 |
469 |
$15K |
| D9990 |
|
618 |
597 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
761 |
742 |
$9K |
| D1206 |
Topical application of fluoride varnish |
322 |
322 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
113 |
99 |
$7K |
| D0240 |
|
329 |
325 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$718.03 |
| D2330 |
|
21 |
16 |
$683.15 |