| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
19,644 |
19,635 |
$1.43M |
| D1110 |
Prophylaxis - adult |
6,195 |
6,193 |
$655K |
| D0210 |
Intraoral - complete series of radiographic images |
3,325 |
3,325 |
$507K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,313 |
3,399 |
$498K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,789 |
1,567 |
$331K |
| D9420 |
|
493 |
493 |
$225K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,956 |
2,956 |
$158K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,642 |
1,642 |
$114K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,828 |
1,820 |
$114K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,768 |
1,477 |
$112K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
383 |
296 |
$75K |
| D0140 |
Limited oral evaluation - problem focused |
1,567 |
1,551 |
$41K |
| D0274 |
Bitewings - four radiographic images |
6,139 |
6,136 |
$40K |
| D0330 |
Panoramic radiographic image |
3,481 |
3,480 |
$32K |
| D1351 |
Sealant - per tooth |
25,781 |
5,094 |
$30K |
| D2332 |
|
234 |
137 |
$16K |
| D2934 |
|
57 |
15 |
$15K |
| D7111 |
|
205 |
148 |
$11K |
| D9248 |
|
167 |
160 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
21,799 |
21,792 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,545 |
6,234 |
$7K |
| D4346 |
|
58 |
58 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
25,812 |
25,801 |
$5K |
| D2331 |
|
65 |
37 |
$2K |
| D2330 |
|
31 |
15 |
$949.30 |
| D0220 |
Intraoral - periapical first radiographic image |
27,033 |
26,842 |
$823.61 |
| D0272 |
Bitewings - two radiographic images |
12,903 |
12,895 |
$425.78 |
| D1206 |
Topical application of fluoride varnish |
936 |
936 |
$193.71 |
| D1330 |
|
392 |
392 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
126 |
65 |
$0.00 |
| D1354 |
|
44 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46,633 |
25,267 |
$-81.37 |