| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
21,271 |
21,270 |
$748K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
10,894 |
7,821 |
$735K |
| D0120 |
Periodic oral evaluation - established patient |
20,971 |
20,970 |
$492K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,028 |
3,167 |
$431K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
7,581 |
5,551 |
$410K |
| D1206 |
Topical application of fluoride varnish |
21,154 |
21,153 |
$391K |
| D1351 |
Sealant - per tooth |
8,025 |
3,229 |
$300K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,958 |
2,426 |
$233K |
| D0272 |
Bitewings - two radiographic images |
19,345 |
19,343 |
$220K |
| D9920 |
|
10,804 |
9,413 |
$161K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,979 |
2,269 |
$153K |
| D1110 |
Prophylaxis - adult |
3,679 |
3,679 |
$143K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,875 |
3,875 |
$95K |
| D0240 |
|
3,703 |
3,402 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
824 |
773 |
$65K |
| D2332 |
|
647 |
582 |
$63K |
| D0140 |
Limited oral evaluation - problem focused |
2,812 |
2,781 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,065 |
2,065 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,239 |
3,239 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,936 |
1,918 |
$15K |
| D1320 |
|
1,948 |
1,948 |
$12K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$4K |
| D2335 |
|
45 |
27 |
$4K |
| D1510 |
|
13 |
12 |
$2K |
| D9110 |
|
129 |
127 |
$1K |
| D2330 |
|
30 |
24 |
$1K |
| D9310 |
|
12 |
12 |
$378.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$300.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$282.00 |
| D0603 |
|
12 |
12 |
$120.00 |