| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,410 |
3,396 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,525 |
3,500 |
$73K |
| D1206 |
Topical application of fluoride varnish |
3,810 |
3,792 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
931 |
591 |
$65K |
| D1110 |
Prophylaxis - adult |
1,332 |
1,321 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
789 |
509 |
$41K |
| D8670 |
Periodic orthodontic treatment visit |
336 |
330 |
$36K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
430 |
163 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
300 |
142 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
447 |
276 |
$29K |
| D1351 |
Sealant - per tooth |
1,058 |
273 |
$25K |
| D0251 |
|
2,166 |
1,281 |
$25K |
| D0274 |
Bitewings - four radiographic images |
504 |
499 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
765 |
761 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
663 |
662 |
$14K |
| D2933 |
|
66 |
24 |
$10K |
| D2330 |
|
133 |
87 |
$6K |
| D2331 |
|
79 |
54 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
41 |
$3K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
62 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
247 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
104 |
$2K |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$445.00 |
| D0240 |
|
14 |
14 |
$170.40 |
| D1999 |
|
708 |
662 |
$157.08 |
| D9995 |
|
28 |
28 |
$0.00 |