| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
25,230 |
25,228 |
$925K |
| D0120 |
Periodic oral evaluation - established patient |
32,355 |
32,354 |
$771K |
| D1351 |
Sealant - per tooth |
11,336 |
3,359 |
$395K |
| D1208 |
Topical application of fluoride, excluding varnish |
30,877 |
30,874 |
$392K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,345 |
3,480 |
$361K |
| D1110 |
Prophylaxis - adult |
7,117 |
7,116 |
$309K |
| D0272 |
Bitewings - two radiographic images |
14,039 |
14,038 |
$183K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,273 |
16,262 |
$136K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,534 |
1,903 |
$128K |
| D0220 |
Intraoral - periapical first radiographic image |
13,892 |
13,836 |
$115K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,230 |
1,602 |
$104K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
970 |
773 |
$97K |
| D0274 |
Bitewings - four radiographic images |
3,181 |
3,180 |
$75K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
835 |
682 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,088 |
2,088 |
$54K |
| D0330 |
Panoramic radiographic image |
1,145 |
1,145 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
449 |
408 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
880 |
870 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
336 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
37 |
$2K |
| D2140 |
|
31 |
17 |
$1K |
| D1999 |
|
94 |
93 |
$600.00 |
| D0603 |
|
14 |
14 |
$14.00 |
| D0602 |
|
12 |
12 |
$12.00 |