| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
14,861 |
14,855 |
$640K |
| D0120 |
Periodic oral evaluation - established patient |
18,343 |
18,336 |
$540K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,641 |
2,053 |
$421K |
| D1208 |
Topical application of fluoride, excluding varnish |
19,941 |
19,934 |
$290K |
| D1110 |
Prophylaxis - adult |
5,128 |
5,126 |
$288K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,530 |
2,283 |
$246K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,070 |
2,376 |
$217K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,523 |
1,214 |
$175K |
| D2160 |
|
1,306 |
1,191 |
$164K |
| D0272 |
Bitewings - two radiographic images |
8,667 |
8,665 |
$150K |
| D1351 |
Sealant - per tooth |
1,704 |
1,035 |
$124K |
| D2140 |
|
1,604 |
1,491 |
$98K |
| D0274 |
Bitewings - four radiographic images |
3,033 |
3,033 |
$89K |
| D0220 |
Intraoral - periapical first radiographic image |
5,821 |
5,788 |
$83K |
| D0330 |
Panoramic radiographic image |
2,230 |
2,230 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,948 |
1,948 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,935 |
3,928 |
$39K |
| D0240 |
|
1,965 |
1,958 |
$28K |
| D9110 |
|
907 |
901 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
1,150 |
1,138 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
211 |
$24K |
| D1510 |
|
90 |
83 |
$12K |
| D9920 |
|
703 |
678 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
102 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
293 |
$4K |
| D2330 |
|
12 |
12 |
$945.60 |
| D9430 |
|
48 |
47 |
$901.60 |
| D1999 |
|
335 |
300 |
$0.00 |