| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,237 |
11,440 |
$556K |
| D1206 |
Topical application of fluoride varnish |
12,477 |
11,692 |
$505K |
| D1351 |
Sealant - per tooth |
11,470 |
2,256 |
$219K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,176 |
5,794 |
$178K |
| D0350 |
|
12,944 |
4,605 |
$157K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,988 |
1,909 |
$150K |
| D0274 |
Bitewings - four radiographic images |
7,241 |
6,781 |
$150K |
| D0120 |
Periodic oral evaluation - established patient |
4,867 |
4,522 |
$117K |
| D0220 |
Intraoral - periapical first radiographic image |
8,861 |
8,133 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,260 |
10,694 |
$90K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,458 |
997 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,641 |
2,427 |
$46K |
| D0330 |
Panoramic radiographic image |
756 |
727 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,021 |
908 |
$16K |
| D1353 |
|
877 |
209 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
484 |
461 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
227 |
226 |
$7K |
| D1110 |
Prophylaxis - adult |
152 |
148 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
228 |
228 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
58 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
106 |
89 |
$6K |
| D7111 |
|
162 |
104 |
$5K |
| D0603 |
|
1,498 |
1,473 |
$4K |
| D0999 |
Unspecified diagnostic procedure, by report |
123 |
123 |
$4K |
| D1999 |
|
85 |
85 |
$1K |
| D3120 |
|
61 |
38 |
$843.22 |
| D0602 |
|
472 |
464 |
$768.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
14 |
$747.00 |
| D0240 |
|
46 |
24 |
$353.50 |
| D0601 |
|
57 |
49 |
$29.00 |
| D9986 |
|
195 |
193 |
$0.00 |