| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,687 |
10,676 |
$394K |
| D1354 |
|
13,288 |
3,976 |
$258K |
| D1351 |
Sealant - per tooth |
4,448 |
1,537 |
$211K |
| D1206 |
Topical application of fluoride varnish |
8,139 |
8,075 |
$204K |
| D0120 |
Periodic oral evaluation - established patient |
8,065 |
8,059 |
$193K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,026 |
719 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,332 |
3,331 |
$84K |
| D1110 |
Prophylaxis - adult |
1,809 |
1,808 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,174 |
801 |
$81K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,016 |
717 |
$74K |
| D0272 |
Bitewings - two radiographic images |
4,226 |
4,226 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,639 |
4,636 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,114 |
846 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
4,931 |
4,879 |
$51K |
| D9999 |
Unspecified adjunctive procedure, by report |
521 |
521 |
$48K |
| D0240 |
|
1,972 |
1,742 |
$42K |
| D0330 |
Panoramic radiographic image |
1,093 |
1,092 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,156 |
1,156 |
$27K |
| D0145 |
Oral evaluation for a patient under three years of age |
974 |
973 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,024 |
3,962 |
$23K |
| D9110 |
|
493 |
484 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
79 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
109 |
$6K |
| D9990 |
|
269 |
254 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
208 |
196 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
367 |
362 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
356 |
356 |
$3K |
| D0601 |
|
1,014 |
1,014 |
$980.00 |
| D0603 |
|
105 |
105 |
$72.00 |
| D0602 |
|
16 |
16 |
$14.00 |
| D1999 |
|
34 |
32 |
$0.00 |