| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,108 |
4,106 |
$144K |
| D1206 |
Topical application of fluoride varnish |
4,489 |
4,485 |
$115K |
| D1351 |
Sealant - per tooth |
5,049 |
1,090 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
4,024 |
4,021 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
844 |
450 |
$59K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
422 |
138 |
$42K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
680 |
201 |
$32K |
| D0330 |
Panoramic radiographic image |
801 |
801 |
$26K |
| D9999 |
Unspecified adjunctive procedure, by report |
40 |
40 |
$22K |
| D9920 |
|
702 |
688 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
215 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,634 |
1,634 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
302 |
197 |
$14K |
| D1110 |
Prophylaxis - adult |
372 |
372 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
578 |
578 |
$10K |
| D0603 |
|
915 |
915 |
$9K |
| D0602 |
|
775 |
775 |
$7K |
| D0274 |
Bitewings - four radiographic images |
562 |
562 |
$7K |
| D0601 |
|
832 |
822 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
280 |
122 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
99 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
438 |
433 |
$2K |
| D2140 |
|
65 |
45 |
$990.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$728.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
247 |
247 |
$664.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$540.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
169 |
$399.00 |
| D9420 |
|
36 |
36 |
$210.00 |