| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,407 |
15,917 |
$219K |
| D0120 |
Periodic oral evaluation - established patient |
19,398 |
18,835 |
$180K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,675 |
2,669 |
$178K |
| D1208 |
Topical application of fluoride, excluding varnish |
20,904 |
20,289 |
$137K |
| D1110 |
Prophylaxis - adult |
4,586 |
4,476 |
$88K |
| D0272 |
Bitewings - two radiographic images |
12,108 |
11,735 |
$80K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,236 |
651 |
$74K |
| D0274 |
Bitewings - four radiographic images |
4,583 |
4,445 |
$58K |
| D0330 |
Panoramic radiographic image |
2,636 |
2,576 |
$52K |
| D1999 |
|
12,654 |
11,809 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
9,205 |
8,886 |
$41K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,664 |
576 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,210 |
709 |
$41K |
| D1351 |
Sealant - per tooth |
3,625 |
1,007 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,138 |
7,879 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,014 |
2,756 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,364 |
1,308 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,162 |
1,079 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
600 |
351 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
684 |
353 |
$10K |
| D9248 |
|
388 |
312 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
766 |
759 |
$5K |
| D2330 |
|
25 |
13 |
$735.60 |
| D9995 |
|
16 |
13 |
$23.73 |
| D0601 |
|
3,650 |
3,389 |
$0.00 |
| D0602 |
|
1,940 |
1,816 |
$0.00 |
| D0603 |
|
2,250 |
2,079 |
$0.00 |