| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,342 |
5,305 |
$297K |
| D1120 |
Prophylaxis - child |
5,303 |
5,263 |
$199K |
| D0350 |
|
18,637 |
5,050 |
$168K |
| D1110 |
Prophylaxis - adult |
1,818 |
1,806 |
$146K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,030 |
2,019 |
$122K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,687 |
904 |
$108K |
| D1351 |
Sealant - per tooth |
3,244 |
721 |
$84K |
| D1206 |
Topical application of fluoride varnish |
5,793 |
5,737 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,698 |
1,686 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,647 |
5,742 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
968 |
475 |
$54K |
| D9430 |
|
1,594 |
1,531 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
896 |
428 |
$46K |
| D1310 |
|
905 |
903 |
$40K |
| D0272 |
Bitewings - two radiographic images |
3,314 |
3,287 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
456 |
280 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,634 |
1,625 |
$33K |
| D9920 |
|
251 |
238 |
$33K |
| D9993 |
|
500 |
500 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
243 |
52 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,730 |
1,649 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
179 |
39 |
$18K |
| D2940 |
|
219 |
194 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,019 |
1,009 |
$10K |
| D0603 |
|
679 |
678 |
$10K |
| D4910 |
|
103 |
102 |
$8K |
| D1320 |
|
411 |
411 |
$5K |
| D9420 |
|
79 |
79 |
$5K |
| D2394 |
|
52 |
37 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
33 |
25 |
$4K |
| D9994 |
|
79 |
74 |
$2K |
| D0322 |
|
20 |
20 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$660.00 |
| D0270 |
|
91 |
89 |
$430.00 |
| D0601 |
|
13 |
13 |
$195.00 |
| D9996 |
|
12 |
12 |
$0.00 |