| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,731 |
12,705 |
$805K |
| D1110 |
Prophylaxis - adult |
7,266 |
7,262 |
$612K |
| D9420 |
|
2,296 |
2,291 |
$601K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
11,235 |
4,788 |
$486K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,563 |
971 |
$145K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,485 |
2,204 |
$126K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
7,110 |
3,389 |
$110K |
| D0330 |
Panoramic radiographic image |
1,554 |
1,553 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
1,136 |
1,130 |
$78K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
727 |
271 |
$75K |
| D0140 |
Limited oral evaluation - problem focused |
1,257 |
1,237 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
12,867 |
12,860 |
$12K |
| D7240 |
Removal of impacted tooth - completely bony |
41 |
12 |
$10K |
| D1351 |
Sealant - per tooth |
10,201 |
2,444 |
$10K |
| D0274 |
Bitewings - four radiographic images |
6,191 |
6,187 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
980 |
978 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,641 |
14,618 |
$2K |
| D2331 |
|
30 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
11,915 |
11,786 |
$928.70 |
| D0220 |
Intraoral - periapical first radiographic image |
4,908 |
4,792 |
$796.70 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$352.21 |
| D7111 |
|
247 |
132 |
$274.60 |
| D2330 |
|
17 |
12 |
$240.28 |
| D1206 |
Topical application of fluoride varnish |
3,137 |
3,134 |
$203.81 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,504 |
2,352 |
$172.51 |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,316 |
3,446 |
$0.00 |
| D3110 |
|
124 |
72 |
$0.00 |
| D4355 |
|
14 |
14 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
12 |
$0.00 |