| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
19,831 |
19,825 |
$666K |
| D0120 |
Periodic oral evaluation - established patient |
20,609 |
20,602 |
$463K |
| D1208 |
Topical application of fluoride, excluding varnish |
19,939 |
19,933 |
$237K |
| D1110 |
Prophylaxis - adult |
3,905 |
3,905 |
$161K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,253 |
808 |
$133K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,400 |
876 |
$112K |
| D0272 |
Bitewings - two radiographic images |
7,671 |
7,649 |
$99K |
| D0240 |
|
4,886 |
3,480 |
$92K |
| D1351 |
Sealant - per tooth |
1,904 |
640 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
7,899 |
7,866 |
$82K |
| D1206 |
Topical application of fluoride varnish |
3,073 |
3,071 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,668 |
2,668 |
$57K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
751 |
549 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,730 |
6,720 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
1,653 |
1,635 |
$19K |
| D0274 |
Bitewings - four radiographic images |
837 |
832 |
$18K |
| D7111 |
|
530 |
390 |
$14K |
| D0330 |
Panoramic radiographic image |
371 |
371 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
406 |
406 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
362 |
362 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
76 |
$4K |
| D2140 |
|
64 |
57 |
$2K |
| D0601 |
|
182 |
136 |
$133.00 |
| D0602 |
|
13 |
13 |
$13.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,433 |
1,427 |
$0.00 |
| D1999 |
|
24 |
24 |
$0.00 |
| D9248 |
|
264 |
263 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
21 |
21 |
$0.00 |