| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
11,007 |
10,971 |
$593K |
| D1120 |
Prophylaxis - child |
12,594 |
12,551 |
$469K |
| D1351 |
Sealant - per tooth |
8,882 |
1,961 |
$246K |
| D1310 |
|
5,412 |
5,397 |
$243K |
| D9993 |
|
3,620 |
3,618 |
$226K |
| D0230 |
Intraoral - periapical each additional radiographic image |
49,215 |
11,703 |
$219K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,874 |
1,489 |
$214K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,023 |
2,220 |
$198K |
| D0220 |
Intraoral - periapical first radiographic image |
12,603 |
12,479 |
$145K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,595 |
1,791 |
$138K |
| D2330 |
|
1,337 |
716 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,486 |
1,481 |
$96K |
| D1206 |
Topical application of fluoride varnish |
4,350 |
4,335 |
$91K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,540 |
1,176 |
$86K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,249 |
8,221 |
$83K |
| D0145 |
Oral evaluation for a patient under three years of age |
892 |
892 |
$52K |
| D0603 |
|
2,682 |
2,678 |
$39K |
| D0601 |
|
1,789 |
1,785 |
$26K |
| D2940 |
|
456 |
240 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
227 |
203 |
$22K |
| D0602 |
|
416 |
414 |
$6K |
| D0350 |
|
346 |
203 |
$3K |
| D1510 |
|
13 |
13 |
$2K |
| D9430 |
|
39 |
39 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$480.00 |
| D9920 |
|
12 |
12 |
$245.00 |
| D0272 |
Bitewings - two radiographic images |
19 |
19 |
$204.00 |
| D1999 |
|
1,197 |
1,171 |
$150.00 |
| D1330 |
|
34 |
34 |
$0.00 |