| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,320 |
5,300 |
$120K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
761 |
284 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
4,838 |
4,820 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,860 |
985 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,264 |
740 |
$44K |
| D1351 |
Sealant - per tooth |
1,636 |
567 |
$37K |
| D1110 |
Prophylaxis - adult |
927 |
922 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,844 |
1,842 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,155 |
4,131 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,536 |
1,530 |
$23K |
| D0330 |
Panoramic radiographic image |
1,201 |
1,198 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,120 |
1,111 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,379 |
1,373 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
99 |
56 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
169 |
169 |
$5K |
| D7111 |
|
62 |
38 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,525 |
2,454 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,293 |
1,241 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
167 |
$162.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,456 |
1,931 |
$18.28 |
| D0240 |
|
125 |
125 |
$0.00 |
| D9248 |
|
74 |
71 |
$0.00 |
| D0603 |
|
63 |
58 |
$0.00 |
| D1354 |
|
298 |
102 |
$0.00 |