| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
14,025 |
12,550 |
$554K |
| D0120 |
Periodic oral evaluation - established patient |
12,249 |
10,924 |
$332K |
| D1351 |
Sealant - per tooth |
5,422 |
2,482 |
$264K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,359 |
9,051 |
$261K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,496 |
1,764 |
$224K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,172 |
11,534 |
$167K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,464 |
1,801 |
$147K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,373 |
3,684 |
$115K |
| D1354 |
|
3,331 |
2,039 |
$104K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,867 |
1,337 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,929 |
3,563 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
14,306 |
12,561 |
$81K |
| D1206 |
Topical application of fluoride varnish |
2,440 |
2,372 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,370 |
1,107 |
$50K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
764 |
615 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,271 |
1,192 |
$24K |
| D9248 |
|
105 |
105 |
$23K |
| D0272 |
Bitewings - two radiographic images |
2,000 |
1,836 |
$21K |
| D1510 |
|
210 |
183 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
904 |
827 |
$14K |
| D1110 |
Prophylaxis - adult |
221 |
220 |
$10K |
| D0330 |
Panoramic radiographic image |
181 |
168 |
$6K |
| D1310 |
|
376 |
376 |
$5K |
| D9110 |
|
60 |
53 |
$3K |
| D1330 |
|
255 |
255 |
$3K |
| D2330 |
|
51 |
43 |
$2K |
| D2331 |
|
30 |
25 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
109 |
$1K |
| D0270 |
|
33 |
33 |
$184.80 |
| D1320 |
|
61 |
61 |
$0.00 |