| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,731 |
2,648 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,535 |
635 |
$83K |
| D1110 |
Prophylaxis - adult |
859 |
830 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
841 |
827 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
2,788 |
2,688 |
$42K |
| D0330 |
Panoramic radiographic image |
243 |
239 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
497 |
287 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
797 |
663 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
407 |
231 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
30 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
89 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
13 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
309 |
290 |
$4K |
| D1351 |
Sealant - per tooth |
521 |
141 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
59 |
59 |
$3K |
| D0272 |
Bitewings - two radiographic images |
2,103 |
2,048 |
$3K |
| D9248 |
|
148 |
137 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,398 |
3,290 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
703 |
661 |
$625.32 |
| D1330 |
|
3,634 |
3,524 |
$526.72 |
| D0274 |
Bitewings - four radiographic images |
737 |
711 |
$166.15 |
| D9986 |
|
700 |
666 |
$96.00 |
| D0601 |
|
1,998 |
1,930 |
$21.00 |
| D0603 |
|
282 |
275 |
$1.00 |
| D0602 |
|
413 |
401 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
24 |
12 |
$0.00 |