| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,897 |
10,879 |
$476K |
| D0120 |
Periodic oral evaluation - established patient |
9,968 |
9,955 |
$270K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,172 |
1,981 |
$262K |
| D1351 |
Sealant - per tooth |
3,728 |
1,225 |
$151K |
| D1206 |
Topical application of fluoride varnish |
4,447 |
4,445 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,833 |
7,821 |
$112K |
| D0272 |
Bitewings - two radiographic images |
6,858 |
6,843 |
$107K |
| D1110 |
Prophylaxis - adult |
1,632 |
1,630 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,470 |
997 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,562 |
2,559 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
5,433 |
5,393 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
961 |
657 |
$50K |
| D0240 |
|
2,256 |
1,468 |
$34K |
| D0274 |
Bitewings - four radiographic images |
970 |
969 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,101 |
3,084 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
142 |
114 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
73 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
418 |
416 |
$6K |
| D9990 |
|
55 |
54 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
32 |
32 |
$926.65 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$163.88 |