| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,269 |
7,069 |
$296K |
| D0120 |
Periodic oral evaluation - established patient |
8,698 |
8,463 |
$240K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,937 |
2,644 |
$217K |
| D1351 |
Sealant - per tooth |
2,031 |
1,632 |
$152K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,734 |
1,596 |
$146K |
| D1206 |
Topical application of fluoride varnish |
4,582 |
4,440 |
$119K |
| D9110 |
|
2,089 |
2,067 |
$113K |
| D1110 |
Prophylaxis - adult |
2,599 |
2,533 |
$113K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
267 |
223 |
$108K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,635 |
1,435 |
$97K |
| D2332 |
|
787 |
707 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,710 |
1,574 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,447 |
2,384 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,513 |
2,439 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
1,753 |
1,727 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
985 |
967 |
$31K |
| D0330 |
Panoramic radiographic image |
989 |
946 |
$24K |
| D0272 |
Bitewings - two radiographic images |
781 |
759 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,053 |
1,031 |
$7K |
| D2330 |
|
97 |
93 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
38 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
25 |
$2K |
| D9310 |
|
75 |
75 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
59 |
$282.24 |