| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,617 |
6,614 |
$295K |
| D1120 |
Prophylaxis - child |
5,990 |
5,990 |
$281K |
| D0120 |
Periodic oral evaluation - established patient |
10,610 |
10,607 |
$270K |
| D1206 |
Topical application of fluoride varnish |
6,714 |
6,714 |
$215K |
| D1351 |
Sealant - per tooth |
7,785 |
1,453 |
$167K |
| D0140 |
Limited oral evaluation - problem focused |
3,035 |
2,770 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,659 |
1,794 |
$144K |
| D8670 |
Periodic orthodontic treatment visit |
2,875 |
2,773 |
$141K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,297 |
583 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,820 |
1,294 |
$78K |
| D2740 |
Crown - porcelain/ceramic |
104 |
89 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
1,184 |
1,184 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,008 |
2,008 |
$53K |
| D7240 |
Removal of impacted tooth - completely bony |
162 |
53 |
$45K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
80 |
73 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
8,243 |
8,123 |
$43K |
| D0274 |
Bitewings - four radiographic images |
3,360 |
3,360 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,720 |
1,581 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,003 |
5,991 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
330 |
254 |
$24K |
| D0330 |
Panoramic radiographic image |
473 |
473 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,742 |
1,742 |
$19K |
| D9310 |
|
827 |
825 |
$15K |
| D0602 |
|
1,735 |
1,735 |
$14K |
| D2954 |
|
124 |
114 |
$14K |
| D0603 |
|
1,483 |
1,483 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
75 |
$11K |
| D0601 |
|
1,258 |
1,258 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
193 |
131 |
$11K |
| D9243 |
|
77 |
77 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
360 |
360 |
$9K |
| D9239 |
|
76 |
76 |
$3K |
| D9612 |
|
55 |
55 |
$2K |
| D4341 |
|
27 |
12 |
$2K |
| D2331 |
|
15 |
12 |
$1K |
| D0350 |
|
445 |
397 |
$642.00 |
| D0340 |
|
14 |
14 |
$252.00 |
| D9910 |
|
28 |
28 |
$147.00 |
| D3910 |
|
20 |
18 |
$20.00 |
| D3950 |
|
18 |
16 |
$18.00 |
| D1999 |
|
7,019 |
6,736 |
$0.00 |