| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
28,046 |
27,911 |
$684K |
| D0120 |
Periodic oral evaluation - established patient |
27,734 |
27,603 |
$555K |
| D1206 |
Topical application of fluoride varnish |
31,848 |
31,691 |
$434K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,795 |
1,119 |
$256K |
| D1351 |
Sealant - per tooth |
16,225 |
3,967 |
$240K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,282 |
3,215 |
$193K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,620 |
1,271 |
$119K |
| D9420 |
|
876 |
833 |
$116K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,195 |
3,169 |
$94K |
| D0210 |
Intraoral - complete series of radiographic images |
2,027 |
2,007 |
$93K |
| D1110 |
Prophylaxis - adult |
3,777 |
3,754 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,390 |
1,648 |
$74K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,637 |
1,128 |
$72K |
| D0272 |
Bitewings - two radiographic images |
8,378 |
8,305 |
$61K |
| D0601 |
|
8,117 |
8,060 |
$53K |
| D0603 |
|
7,099 |
7,062 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
1,451 |
1,431 |
$46K |
| D0330 |
Panoramic radiographic image |
3,101 |
3,080 |
$37K |
| D0274 |
Bitewings - four radiographic images |
4,110 |
4,080 |
$28K |
| D0602 |
|
3,624 |
3,604 |
$27K |
| D9920 |
|
728 |
727 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,528 |
2,472 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
257 |
139 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
92 |
$4K |
| D2140 |
|
67 |
54 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
153 |
153 |
$2K |
| D2330 |
|
37 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
533 |
244 |
$1K |
| D2331 |
|
18 |
13 |
$879.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
482 |
482 |
$450.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
113 |
111 |
$110.00 |
| D1999 |
|
566 |
542 |
$0.00 |
| D1330 |
|
37 |
37 |
$0.00 |