| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
20,150 |
19,736 |
$996K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,574 |
1,804 |
$708K |
| D1110 |
Prophylaxis - adult |
9,675 |
9,474 |
$527K |
| D0330 |
Panoramic radiographic image |
4,711 |
4,620 |
$389K |
| D0120 |
Periodic oral evaluation - established patient |
24,955 |
24,464 |
$295K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,363 |
2,134 |
$203K |
| D1351 |
Sealant - per tooth |
23,036 |
5,266 |
$155K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,971 |
1,874 |
$94K |
| D7111 |
|
2,764 |
1,537 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
21,435 |
21,008 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,213 |
5,075 |
$79K |
| D0272 |
Bitewings - two radiographic images |
19,679 |
19,249 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
489 |
368 |
$44K |
| D1330 |
|
30,173 |
29,543 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,755 |
744 |
$32K |
| D1206 |
Topical application of fluoride varnish |
7,957 |
7,772 |
$31K |
| D9999 |
Unspecified adjunctive procedure, by report |
786 |
755 |
$26K |
| D1510 |
|
311 |
218 |
$19K |
| D9420 |
|
476 |
472 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
1,240 |
1,206 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
9,847 |
9,519 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,320 |
2,209 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,833 |
4,773 |
$11K |
| D1354 |
|
1,849 |
805 |
$6K |
| D2931 |
|
26 |
21 |
$5K |
| D0601 |
|
1,423 |
1,422 |
$2K |
| D1999 |
|
46 |
46 |
$2K |
| D0603 |
|
1,324 |
1,311 |
$1K |
| D0602 |
|
1,202 |
1,197 |
$1K |
| D2950 |
|
44 |
34 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
50 |
50 |
$1K |
| D0274 |
Bitewings - four radiographic images |
451 |
449 |
$526.66 |
| D2330 |
|
44 |
24 |
$151.81 |
| D0270 |
|
113 |
113 |
$26.88 |
| D3120 |
|
21 |
14 |
$0.00 |