| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
22,386 |
22,384 |
$751K |
| D0120 |
Periodic oral evaluation - established patient |
18,904 |
18,903 |
$424K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,902 |
4,661 |
$401K |
| D1206 |
Topical application of fluoride varnish |
12,868 |
12,867 |
$308K |
| D0220 |
Intraoral - periapical first radiographic image |
18,038 |
17,884 |
$190K |
| D0272 |
Bitewings - two radiographic images |
10,622 |
10,621 |
$134K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,790 |
2,499 |
$127K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,080 |
10,080 |
$113K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,312 |
4,311 |
$94K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,947 |
14,933 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,783 |
1,572 |
$69K |
| D1351 |
Sealant - per tooth |
1,292 |
780 |
$69K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
800 |
766 |
$65K |
| D1354 |
|
2,510 |
1,102 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
4,264 |
4,215 |
$48K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
790 |
756 |
$47K |
| D0330 |
Panoramic radiographic image |
1,350 |
1,350 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,036 |
1,004 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,391 |
1,391 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
400 |
376 |
$27K |
| D1110 |
Prophylaxis - adult |
574 |
574 |
$25K |
| D2332 |
|
29 |
25 |
$2K |
| D0270 |
|
156 |
156 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$602.06 |
| D0603 |
|
28 |
28 |
$280.00 |
| D1999 |
|
127 |
120 |
$0.00 |