| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
18,730 |
18,726 |
$644K |
| D0120 |
Periodic oral evaluation - established patient |
19,181 |
19,177 |
$443K |
| D1351 |
Sealant - per tooth |
7,537 |
3,449 |
$367K |
| D1206 |
Topical application of fluoride varnish |
14,745 |
14,726 |
$353K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,990 |
1,482 |
$220K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,822 |
2,176 |
$203K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,370 |
2,566 |
$186K |
| D0272 |
Bitewings - two radiographic images |
12,872 |
12,870 |
$170K |
| D1110 |
Prophylaxis - adult |
3,558 |
3,558 |
$164K |
| D0220 |
Intraoral - periapical first radiographic image |
13,841 |
13,596 |
$150K |
| D0330 |
Panoramic radiographic image |
2,866 |
2,865 |
$99K |
| D0240 |
|
4,108 |
3,893 |
$98K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,321 |
8,320 |
$93K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,975 |
10,851 |
$84K |
| D1354 |
|
3,584 |
1,605 |
$72K |
| D0274 |
Bitewings - four radiographic images |
2,940 |
2,940 |
$66K |
| D7111 |
|
1,864 |
1,547 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,226 |
2,226 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,179 |
1,015 |
$49K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
589 |
489 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
2,758 |
2,461 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
797 |
797 |
$19K |
| D9110 |
|
794 |
776 |
$17K |
| D2335 |
|
112 |
94 |
$15K |
| D9996 |
|
1,063 |
1,038 |
$13K |
| D2332 |
|
94 |
89 |
$8K |
| D0350 |
|
853 |
836 |
$8K |
| D9920 |
|
267 |
257 |
$4K |
| D2330 |
|
40 |
39 |
$2K |
| D9310 |
|
28 |
28 |
$2K |
| D1510 |
|
18 |
17 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
127 |
$2K |
| D1999 |
|
128 |
123 |
$0.00 |
| D0602 |
|
1,205 |
1,205 |
$0.00 |
| D0601 |
|
315 |
315 |
$0.00 |
| D0603 |
|
6,711 |
6,708 |
$0.00 |