| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,659 |
10,640 |
$480K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,743 |
2,245 |
$411K |
| D0120 |
Periodic oral evaluation - established patient |
11,093 |
11,072 |
$337K |
| D2394 |
|
2,257 |
1,971 |
$329K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,611 |
2,198 |
$260K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,391 |
2,812 |
$208K |
| D1110 |
Prophylaxis - adult |
3,431 |
3,426 |
$205K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,053 |
1,612 |
$177K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,551 |
1,300 |
$174K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,502 |
1,295 |
$171K |
| D1351 |
Sealant - per tooth |
2,304 |
1,048 |
$138K |
| D1206 |
Topical application of fluoride varnish |
4,419 |
4,412 |
$138K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,793 |
8,782 |
$128K |
| D0274 |
Bitewings - four radiographic images |
3,786 |
3,784 |
$106K |
| D0272 |
Bitewings - two radiographic images |
6,059 |
6,046 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,070 |
3,070 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
6,349 |
6,272 |
$85K |
| D0210 |
Intraoral - complete series of radiographic images |
2,051 |
2,034 |
$61K |
| D0330 |
Panoramic radiographic image |
1,473 |
1,472 |
$56K |
| D9310 |
|
440 |
440 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,085 |
5,080 |
$36K |
| D2335 |
|
185 |
158 |
$36K |
| D9996 |
|
2,022 |
1,925 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
1,665 |
1,642 |
$23K |
| D9920 |
|
238 |
224 |
$7K |
| D1320 |
|
858 |
857 |
$7K |
| D2161 |
|
14 |
12 |
$2K |
| D9110 |
|
71 |
71 |
$2K |
| D0270 |
|
64 |
63 |
$792.96 |
| D9991 |
|
19 |
18 |
$190.00 |