| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
35,798 |
35,792 |
$1.89M |
| D0120 |
Periodic oral evaluation - established patient |
47,251 |
47,245 |
$1.29M |
| D1120 |
Prophylaxis - child |
15,987 |
15,987 |
$678K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,679 |
5,636 |
$661K |
| D0274 |
Bitewings - four radiographic images |
24,463 |
24,458 |
$601K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,326 |
1,248 |
$348K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,151 |
2,221 |
$344K |
| D1206 |
Topical application of fluoride varnish |
12,266 |
12,265 |
$318K |
| D1351 |
Sealant - per tooth |
5,192 |
2,221 |
$264K |
| D0330 |
Panoramic radiographic image |
6,033 |
6,032 |
$200K |
| D0220 |
Intraoral - periapical first radiographic image |
15,489 |
15,343 |
$167K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,680 |
2,143 |
$162K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,265 |
983 |
$129K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,278 |
4,278 |
$126K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,260 |
7,260 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,375 |
8,087 |
$85K |
| D1354 |
|
3,614 |
1,309 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,111 |
776 |
$59K |
| D8670 |
Periodic orthodontic treatment visit |
506 |
504 |
$59K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
551 |
384 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
3,283 |
3,267 |
$45K |
| D2954 |
|
243 |
211 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,056 |
2,056 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
1,362 |
1,359 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
765 |
765 |
$22K |
| D9310 |
|
430 |
430 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,427 |
2,355 |
$20K |
| D2394 |
|
148 |
118 |
$19K |
| D2740 |
Crown - porcelain/ceramic |
26 |
25 |
$15K |
| D7111 |
|
153 |
137 |
$7K |
| D0340 |
|
71 |
71 |
$4K |
| D0350 |
|
97 |
97 |
$1K |
| D8660 |
|
44 |
44 |
$1K |
| D4910 |
|
16 |
16 |
$855.41 |
| D1999 |
|
6,870 |
6,489 |
$130.00 |
| D0603 |
|
113 |
113 |
$88.00 |
| D0602 |
|
59 |
59 |
$39.00 |
| D0601 |
|
18 |
18 |
$8.00 |
| D9920 |
|
12 |
12 |
$0.00 |