| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,829 |
4,829 |
$237K |
| D1120 |
Prophylaxis - child |
4,156 |
4,154 |
$187K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,765 |
1,120 |
$140K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
927 |
446 |
$107K |
| D1206 |
Topical application of fluoride varnish |
3,458 |
3,458 |
$56K |
| D1351 |
Sealant - per tooth |
1,421 |
499 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
676 |
494 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,939 |
2,939 |
$36K |
| D1110 |
Prophylaxis - adult |
653 |
653 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
336 |
224 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
472 |
321 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,696 |
1,683 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,335 |
1,335 |
$17K |
| D0274 |
Bitewings - four radiographic images |
847 |
847 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,273 |
2,268 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
216 |
216 |
$5K |
| D2332 |
|
17 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$529.00 |
| D1999 |
|
77 |
69 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
17 |
$0.00 |
| D0603 |
|
63 |
63 |
$0.00 |
| D1330 |
|
46 |
46 |
$0.00 |