| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,950 |
5,933 |
$251K |
| D0120 |
Periodic oral evaluation - established patient |
7,327 |
7,303 |
$209K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,712 |
5,694 |
$153K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,233 |
1,916 |
$150K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,475 |
1,318 |
$138K |
| D1351 |
Sealant - per tooth |
1,611 |
1,185 |
$121K |
| D0274 |
Bitewings - four radiographic images |
4,064 |
4,045 |
$80K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
775 |
503 |
$78K |
| D4341 |
|
418 |
264 |
$71K |
| D1110 |
Prophylaxis - adult |
1,252 |
1,250 |
$60K |
| D0330 |
Panoramic radiographic image |
1,913 |
1,905 |
$52K |
| D4342 |
|
428 |
284 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,600 |
1,592 |
$41K |
| D9110 |
|
735 |
716 |
$40K |
| D2740 |
Crown - porcelain/ceramic |
106 |
100 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
686 |
618 |
$29K |
| D2332 |
|
248 |
218 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
252 |
185 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,691 |
2,660 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,362 |
1,361 |
$15K |
| D2394 |
|
131 |
119 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,584 |
1,563 |
$12K |
| D2950 |
|
130 |
123 |
$9K |
| D9630 |
|
270 |
270 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
46 |
45 |
$5K |
| D2335 |
|
47 |
43 |
$5K |
| D2160 |
|
34 |
29 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
120 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
32 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
12 |
12 |
$909.12 |
| D4910 |
|
12 |
12 |
$804.00 |