| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,718 |
15,716 |
$666K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,015 |
3,064 |
$625K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,809 |
1,767 |
$546K |
| D0120 |
Periodic oral evaluation - established patient |
14,862 |
14,860 |
$505K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,609 |
16,606 |
$454K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,068 |
2,407 |
$360K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,461 |
1,574 |
$314K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,275 |
1,759 |
$214K |
| D0220 |
Intraoral - periapical first radiographic image |
9,508 |
9,459 |
$177K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,824 |
7,268 |
$157K |
| D0272 |
Bitewings - two radiographic images |
5,638 |
5,635 |
$141K |
| D9920 |
|
2,289 |
2,278 |
$112K |
| D0140 |
Limited oral evaluation - problem focused |
1,695 |
1,682 |
$105K |
| D0330 |
Panoramic radiographic image |
1,343 |
1,343 |
$98K |
| D1110 |
Prophylaxis - adult |
1,912 |
1,911 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,452 |
1,452 |
$89K |
| D0145 |
Oral evaluation for a patient under three years of age |
914 |
914 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
223 |
196 |
$35K |
| D1351 |
Sealant - per tooth |
1,071 |
473 |
$32K |
| D2390 |
|
125 |
52 |
$26K |
| D1206 |
Topical application of fluoride varnish |
755 |
755 |
$25K |
| D2330 |
|
42 |
36 |
$4K |