| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
25,500 |
25,499 |
$804K |
| D0120 |
Periodic oral evaluation - established patient |
30,394 |
30,393 |
$650K |
| D1351 |
Sealant - per tooth |
6,781 |
3,541 |
$383K |
| D1208 |
Topical application of fluoride, excluding varnish |
30,872 |
30,871 |
$337K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,705 |
3,940 |
$336K |
| D1110 |
Prophylaxis - adult |
5,234 |
5,234 |
$221K |
| D0272 |
Bitewings - two radiographic images |
15,315 |
15,315 |
$192K |
| D0220 |
Intraoral - periapical first radiographic image |
18,055 |
17,964 |
$187K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,506 |
1,379 |
$133K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,951 |
13,948 |
$90K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,314 |
1,201 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,180 |
1,996 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,524 |
1,377 |
$73K |
| D0330 |
Panoramic radiographic image |
1,797 |
1,797 |
$51K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
530 |
513 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,714 |
1,714 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
1,294 |
1,274 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
522 |
522 |
$12K |
| D1206 |
Topical application of fluoride varnish |
145 |
145 |
$4K |
| D0270 |
|
15 |
15 |
$149.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$80.15 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
109 |
103 |
$0.00 |
| D1999 |
|
329 |
323 |
$0.00 |