| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,108 |
2,105 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
583 |
436 |
$44K |
| D0330 |
Panoramic radiographic image |
377 |
375 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
182 |
$14K |
| D1351 |
Sealant - per tooth |
532 |
187 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
154 |
106 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
828 |
783 |
$6K |
| D1110 |
Prophylaxis - adult |
82 |
82 |
$4K |
| D0603 |
|
106 |
106 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
2,066 |
2,063 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
26 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
14 |
$1K |
| D1999 |
|
26 |
26 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
44 |
44 |
$880.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
34 |
34 |
$680.00 |
| D0220 |
Intraoral - periapical first radiographic image |
281 |
267 |
$601.35 |
| D0602 |
|
15 |
15 |
$490.00 |
| D0272 |
Bitewings - two radiographic images |
1,899 |
1,894 |
$438.31 |
| D0601 |
|
13 |
13 |
$393.00 |
| D1330 |
|
1,410 |
1,408 |
$349.74 |
| D0240 |
|
132 |
70 |
$277.78 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$275.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,209 |
2,206 |
$163.00 |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$40.60 |
| D0350 |
|
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
13 |
$0.00 |