| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,757 |
7,748 |
$274K |
| D1206 |
Topical application of fluoride varnish |
8,556 |
8,541 |
$231K |
| D0120 |
Periodic oral evaluation - established patient |
7,050 |
7,044 |
$192K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,062 |
1,279 |
$139K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,642 |
1,671 |
$57K |
| D1351 |
Sealant - per tooth |
2,901 |
614 |
$54K |
| D0272 |
Bitewings - two radiographic images |
2,695 |
2,689 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
890 |
882 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
409 |
314 |
$35K |
| D0330 |
Panoramic radiographic image |
630 |
629 |
$30K |
| D0601 |
|
2,733 |
2,733 |
$27K |
| D0240 |
|
1,722 |
1,544 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
187 |
121 |
$24K |
| D1110 |
Prophylaxis - adult |
495 |
490 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,980 |
1,968 |
$19K |
| D0274 |
Bitewings - four radiographic images |
808 |
805 |
$18K |
| D0602 |
|
2,224 |
2,213 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
164 |
163 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
75 |
$9K |
| D0603 |
|
804 |
804 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
49 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
249 |
249 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
73 |
52 |
$3K |
| D9920 |
|
84 |
80 |
$2K |
| D0350 |
|
1,563 |
1,563 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$406.00 |
| D1999 |
|
72 |
71 |
$0.00 |