| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,386 |
9,372 |
$679K |
| D0274 |
Bitewings - four radiographic images |
2,521 |
2,517 |
$308K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,734 |
1,701 |
$255K |
| D0330 |
Panoramic radiographic image |
1,258 |
1,257 |
$139K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,151 |
1,522 |
$115K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
771 |
267 |
$85K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,145 |
1,151 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,062 |
1,059 |
$67K |
| D1110 |
Prophylaxis - adult |
3,200 |
3,194 |
$61K |
| D9420 |
|
344 |
344 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
1,462 |
1,429 |
$35K |
| D1351 |
Sealant - per tooth |
13,644 |
2,965 |
$7K |
| D1206 |
Topical application of fluoride varnish |
2,383 |
2,380 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
11,402 |
11,385 |
$719.05 |
| D2331 |
|
27 |
12 |
$377.81 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
303 |
164 |
$264.51 |
| D0220 |
Intraoral - periapical first radiographic image |
10,437 |
10,228 |
$215.93 |
| D0170 |
|
20 |
20 |
$114.52 |
| D0272 |
Bitewings - two radiographic images |
6,595 |
6,571 |
$63.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
9,723 |
9,706 |
$-13.51 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,711 |
2,628 |
$-546.87 |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,574 |
9,288 |
$-945.20 |