| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,080 |
8,080 |
$286K |
| D0120 |
Periodic oral evaluation - established patient |
8,073 |
8,073 |
$195K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,632 |
1,527 |
$176K |
| D1206 |
Topical application of fluoride varnish |
6,239 |
6,239 |
$158K |
| D1351 |
Sealant - per tooth |
3,749 |
1,165 |
$134K |
| D1110 |
Prophylaxis - adult |
1,426 |
1,426 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,362 |
891 |
$60K |
| D0272 |
Bitewings - two radiographic images |
3,949 |
3,948 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,665 |
2,665 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,133 |
1,133 |
$28K |
| D0240 |
|
1,385 |
1,030 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
498 |
345 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,093 |
1,087 |
$12K |
| D0330 |
Panoramic radiographic image |
208 |
208 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
67 |
54 |
$6K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
400 |
382 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
264 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
165 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$1K |
| D1999 |
|
14 |
13 |
$0.00 |