| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
19,728 |
19,491 |
$699K |
| D0120 |
Periodic oral evaluation - established patient |
23,731 |
23,449 |
$655K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,422 |
2,988 |
$458K |
| D1110 |
Prophylaxis - adult |
8,972 |
8,848 |
$429K |
| D1208 |
Topical application of fluoride, excluding varnish |
17,554 |
17,308 |
$351K |
| D1351 |
Sealant - per tooth |
11,471 |
4,126 |
$350K |
| D0272 |
Bitewings - two radiographic images |
14,588 |
14,382 |
$307K |
| D0330 |
Panoramic radiographic image |
4,113 |
4,048 |
$243K |
| D0220 |
Intraoral - periapical first radiographic image |
16,808 |
16,109 |
$238K |
| D1206 |
Topical application of fluoride varnish |
7,917 |
7,846 |
$198K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,042 |
14,935 |
$188K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,482 |
4,208 |
$158K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,449 |
911 |
$146K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,967 |
2,887 |
$137K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,191 |
1,141 |
$136K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,539 |
2,518 |
$118K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
905 |
429 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,474 |
959 |
$97K |
| D9248 |
|
632 |
554 |
$56K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
617 |
323 |
$56K |
| D1354 |
|
2,158 |
516 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
703 |
671 |
$9K |
| D7240 |
Removal of impacted tooth - completely bony |
24 |
12 |
$6K |
| D2330 |
|
52 |
28 |
$3K |
| D9243 |
|
39 |
13 |
$3K |
| D2332 |
|
21 |
13 |
$2K |
| D9239 |
|
13 |
13 |
$1K |
| D1999 |
|
201 |
174 |
$35.00 |
| D0350 |
|
117 |
100 |
$0.00 |
| D3120 |
|
216 |
106 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |