| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,770 |
7,770 |
$364K |
| D1351 |
Sealant - per tooth |
5,520 |
1,920 |
$341K |
| D0120 |
Periodic oral evaluation - established patient |
9,615 |
9,615 |
$305K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,078 |
1,527 |
$203K |
| D1110 |
Prophylaxis - adult |
3,004 |
3,004 |
$191K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
926 |
779 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,291 |
7,291 |
$112K |
| D0220 |
Intraoral - periapical first radiographic image |
7,148 |
7,131 |
$109K |
| D1206 |
Topical application of fluoride varnish |
3,488 |
3,485 |
$104K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
955 |
804 |
$100K |
| D0274 |
Bitewings - four radiographic images |
2,480 |
2,480 |
$79K |
| D0272 |
Bitewings - two radiographic images |
3,954 |
3,954 |
$73K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,338 |
954 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
998 |
860 |
$69K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
483 |
420 |
$58K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
480 |
383 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,422 |
6,421 |
$52K |
| D0160 |
|
1,137 |
1,137 |
$36K |
| D1320 |
|
2,819 |
2,816 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
285 |
278 |
$9K |
| D2140 |
|
87 |
80 |
$6K |
| D9110 |
|
124 |
122 |
$4K |
| D2160 |
|
14 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$871.80 |
| D0601 |
|
620 |
620 |
$0.00 |
| D0602 |
|
474 |
474 |
$0.00 |
| D0603 |
|
133 |
133 |
$0.00 |