| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,463 |
9,459 |
$304K |
| D1351 |
Sealant - per tooth |
7,046 |
2,186 |
$301K |
| D0120 |
Periodic oral evaluation - established patient |
11,169 |
11,159 |
$240K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,503 |
2,195 |
$233K |
| D1110 |
Prophylaxis - adult |
4,446 |
4,444 |
$184K |
| D2335 |
|
1,108 |
577 |
$170K |
| D0220 |
Intraoral - periapical first radiographic image |
12,745 |
12,643 |
$128K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,312 |
988 |
$104K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,456 |
11,411 |
$97K |
| D2394 |
|
811 |
526 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,788 |
3,786 |
$86K |
| D0272 |
Bitewings - two radiographic images |
6,768 |
6,747 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,638 |
6,636 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,640 |
2,640 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,383 |
970 |
$54K |
| D2752 |
|
119 |
31 |
$47K |
| D3240 |
|
291 |
195 |
$44K |
| D0274 |
Bitewings - four radiographic images |
2,030 |
2,030 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
467 |
272 |
$37K |
| D2750 |
|
74 |
68 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
3,240 |
3,234 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
2,862 |
2,818 |
$30K |
| D0330 |
Panoramic radiographic image |
1,198 |
1,196 |
$28K |
| D7111 |
|
813 |
613 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
380 |
247 |
$13K |
| D2954 |
|
127 |
97 |
$13K |
| D1510 |
|
112 |
97 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
149 |
147 |
$5K |
| D2331 |
|
62 |
51 |
$5K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
15 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
75 |
75 |
$2K |
| D9110 |
|
25 |
25 |
$425.91 |
| D0270 |
|
13 |
13 |
$116.41 |
| D1999 |
|
314 |
279 |
$0.00 |