| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,049 |
11,700 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
11,354 |
10,974 |
$44K |
| D1206 |
Topical application of fluoride varnish |
15,439 |
14,955 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,046 |
323 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
745 |
654 |
$24K |
| D1351 |
Sealant - per tooth |
8,722 |
2,260 |
$22K |
| D1110 |
Prophylaxis - adult |
3,388 |
3,264 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,396 |
1,423 |
$20K |
| D0274 |
Bitewings - four radiographic images |
6,488 |
6,077 |
$19K |
| D0272 |
Bitewings - two radiographic images |
6,724 |
6,439 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
791 |
485 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
6,585 |
6,070 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,601 |
2,556 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,247 |
1,201 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,163 |
5,012 |
$5K |
| D0330 |
Panoramic radiographic image |
2,722 |
2,427 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
741 |
691 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
304 |
292 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
24 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
256 |
149 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
25 |
$613.04 |
| D9248 |
|
26 |
26 |
$491.26 |
| D1354 |
|
4,030 |
947 |
$0.00 |
| D0350 |
|
1,397 |
1,387 |
$0.00 |
| D0603 |
|
3,568 |
3,425 |
$0.00 |
| D0602 |
|
3,368 |
3,316 |
$0.00 |