| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
1,164 |
1,148 |
$101K |
| D1120 |
Prophylaxis - child |
2,440 |
2,410 |
$63K |
| D1110 |
Prophylaxis - adult |
1,002 |
990 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
974 |
629 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,403 |
2,367 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,089 |
1,079 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
624 |
436 |
$20K |
| D1351 |
Sealant - per tooth |
4,445 |
982 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,359 |
3,311 |
$12K |
| D0274 |
Bitewings - four radiographic images |
1,305 |
1,280 |
$4K |
| D1330 |
|
3,442 |
3,392 |
$3K |
| D0272 |
Bitewings - two radiographic images |
881 |
870 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
85 |
85 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
636 |
588 |
$884.03 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$828.39 |
| D0140 |
Limited oral evaluation - problem focused |
129 |
123 |
$771.39 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$560.01 |
| D1999 |
|
15 |
13 |
$508.34 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
18 |
$117.44 |