| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
18,418 |
18,378 |
$1.37M |
| D1110 |
Prophylaxis - adult |
5,521 |
5,509 |
$573K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,682 |
2,898 |
$350K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,855 |
1,278 |
$282K |
| D0330 |
Panoramic radiographic image |
2,173 |
2,166 |
$227K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,989 |
1,523 |
$118K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,088 |
2,087 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,462 |
1,453 |
$95K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,265 |
1,192 |
$79K |
| D9248 |
|
204 |
202 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,425 |
1,404 |
$44K |
| D9420 |
|
183 |
182 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
21,611 |
21,569 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
70 |
$15K |
| D1351 |
Sealant - per tooth |
11,352 |
2,237 |
$7K |
| D0274 |
Bitewings - four radiographic images |
4,271 |
4,265 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,898 |
5,566 |
$1K |
| D2330 |
|
21 |
12 |
$430.64 |
| D1206 |
Topical application of fluoride varnish |
14,331 |
14,297 |
$418.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
11,552 |
11,538 |
$203.77 |
| D0220 |
Intraoral - periapical first radiographic image |
23,639 |
23,454 |
$142.11 |
| D1999 |
|
3,113 |
3,102 |
$0.00 |
| D9986 |
|
141 |
140 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
43 |
25 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13,100 |
13,066 |
$-726.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34,287 |
21,631 |
$-2753.41 |