| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
22,780 |
22,779 |
$974K |
| D0120 |
Periodic oral evaluation - established patient |
25,745 |
25,744 |
$684K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,160 |
1,674 |
$653K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,034 |
3,766 |
$512K |
| D1351 |
Sealant - per tooth |
5,859 |
3,565 |
$350K |
| D1208 |
Topical application of fluoride, excluding varnish |
24,508 |
24,506 |
$347K |
| D1110 |
Prophylaxis - adult |
4,447 |
4,447 |
$227K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,527 |
1,124 |
$221K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,855 |
1,990 |
$194K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,457 |
1,903 |
$158K |
| D0330 |
Panoramic radiographic image |
3,024 |
3,024 |
$106K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,360 |
5,921 |
$104K |
| D0220 |
Intraoral - periapical first radiographic image |
7,849 |
7,826 |
$87K |
| D0272 |
Bitewings - two radiographic images |
3,677 |
3,677 |
$54K |
| D0274 |
Bitewings - four radiographic images |
2,113 |
2,113 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,279 |
1,279 |
$39K |
| D9110 |
|
1,040 |
1,033 |
$28K |
| D1354 |
|
1,273 |
818 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,107 |
3,036 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
655 |
654 |
$15K |
| D2335 |
|
90 |
49 |
$13K |
| D2330 |
|
181 |
141 |
$11K |
| D1206 |
Topical application of fluoride varnish |
260 |
260 |
$8K |
| D2332 |
|
30 |
29 |
$5K |
| D9999 |
Unspecified adjunctive procedure, by report |
56 |
56 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
38 |
$3K |
| D0601 |
|
598 |
598 |
$533.00 |
| D0602 |
|
410 |
410 |
$330.00 |
| D0603 |
|
256 |
256 |
$221.00 |