| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,046 |
7,929 |
$278K |
| D1110 |
Prophylaxis - adult |
3,401 |
3,346 |
$186K |
| D0210 |
Intraoral - complete series of radiographic images |
2,162 |
2,135 |
$179K |
| D0120 |
Periodic oral evaluation - established patient |
9,213 |
9,075 |
$115K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
816 |
367 |
$102K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,259 |
3,836 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,876 |
902 |
$75K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
395 |
235 |
$50K |
| D1351 |
Sealant - per tooth |
2,388 |
628 |
$36K |
| D1206 |
Topical application of fluoride varnish |
11,642 |
11,464 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
1,437 |
1,379 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,723 |
1,704 |
$11K |
| D0274 |
Bitewings - four radiographic images |
2,913 |
2,869 |
$11K |
| D9920 |
|
468 |
443 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
585 |
257 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
715 |
706 |
$8K |
| D1330 |
|
11,640 |
11,464 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
22 |
14 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
5,231 |
5,137 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
43 |
$4K |
| D0272 |
Bitewings - two radiographic images |
2,931 |
2,890 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
107 |
107 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
41 |
$2K |
| D1999 |
|
22 |
22 |
$1K |
| D7111 |
|
35 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
12 |
$955.28 |
| D0999 |
Unspecified diagnostic procedure, by report |
18 |
18 |
$360.00 |
| D0601 |
|
8,164 |
8,047 |
$252.58 |
| D0602 |
|
711 |
699 |
$174.74 |
| D4355 |
|
14 |
14 |
$154.00 |
| D3120 |
|
43 |
25 |
$98.52 |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$63.91 |
| D0603 |
|
1,901 |
1,872 |
$51.89 |
| D9986 |
|
3,403 |
3,297 |
$0.00 |