| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,978 |
15,975 |
$554K |
| D1206 |
Topical application of fluoride varnish |
14,298 |
14,071 |
$346K |
| D1351 |
Sealant - per tooth |
6,409 |
3,087 |
$312K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,101 |
2,144 |
$307K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,864 |
3,004 |
$284K |
| D0120 |
Periodic oral evaluation - established patient |
12,197 |
12,191 |
$283K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,882 |
3,922 |
$242K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,677 |
11,651 |
$200K |
| D1354 |
|
11,465 |
3,302 |
$188K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,084 |
1,559 |
$156K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,886 |
1,543 |
$145K |
| D0220 |
Intraoral - periapical first radiographic image |
12,379 |
12,291 |
$136K |
| D0240 |
|
4,575 |
4,538 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,258 |
3,258 |
$78K |
| D1110 |
Prophylaxis - adult |
1,179 |
1,179 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,721 |
4,719 |
$53K |
| D3240 |
|
309 |
149 |
$50K |
| D0272 |
Bitewings - two radiographic images |
3,760 |
3,760 |
$50K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,020 |
2,019 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
906 |
810 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,816 |
1,816 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
3,427 |
3,316 |
$39K |
| D0330 |
Panoramic radiographic image |
1,060 |
1,060 |
$36K |
| D2335 |
|
278 |
216 |
$35K |
| D2394 |
|
305 |
275 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
2,261 |
2,250 |
$16K |
| D9110 |
|
501 |
500 |
$10K |
| D0273 |
|
241 |
241 |
$4K |
| D9920 |
|
84 |
82 |
$1K |
| D0270 |
|
27 |
27 |
$300.60 |
| D0603 |
|
321 |
321 |
$0.00 |