| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,546 |
6,401 |
$385K |
| D0120 |
Periodic oral evaluation - established patient |
11,189 |
10,948 |
$296K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,553 |
1,963 |
$192K |
| D0330 |
Panoramic radiographic image |
2,077 |
2,026 |
$168K |
| D0274 |
Bitewings - four radiographic images |
6,615 |
6,469 |
$76K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
367 |
197 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,217 |
1,396 |
$67K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
511 |
369 |
$62K |
| D1351 |
Sealant - per tooth |
8,865 |
2,304 |
$57K |
| D0272 |
Bitewings - two radiographic images |
5,251 |
5,141 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,498 |
1,472 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
843 |
501 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
132 |
$23K |
| D1330 |
|
12,703 |
12,434 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,605 |
12,346 |
$20K |
| D1120 |
Prophylaxis - child |
6,132 |
6,013 |
$18K |
| D7111 |
|
249 |
154 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
13,137 |
12,792 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
720 |
700 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,729 |
12,285 |
$6K |
| D2332 |
|
16 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
295 |
157 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$300.00 |
| D9995 |
|
29 |
29 |
$76.78 |