| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,502 |
6,001 |
$258K |
| D1206 |
Topical application of fluoride varnish |
6,383 |
5,889 |
$209K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,095 |
708 |
$172K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,453 |
3,247 |
$103K |
| D0272 |
Bitewings - two radiographic images |
4,559 |
4,212 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
3,005 |
2,781 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,203 |
6,036 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,253 |
496 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
6,832 |
6,262 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,265 |
621 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,384 |
1,230 |
$39K |
| D0330 |
Panoramic radiographic image |
1,184 |
1,108 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,716 |
1,531 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
421 |
183 |
$17K |
| D9248 |
|
206 |
186 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
152 |
$11K |
| D1110 |
Prophylaxis - adult |
247 |
231 |
$10K |
| D1351 |
Sealant - per tooth |
514 |
111 |
$10K |
| D9999 |
Unspecified adjunctive procedure, by report |
280 |
242 |
$6K |
| D0999 |
Unspecified diagnostic procedure, by report |
252 |
208 |
$6K |
| D0274 |
Bitewings - four radiographic images |
274 |
248 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
249 |
216 |
$4K |
| D9420 |
|
125 |
96 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
316 |
299 |
$3K |
| D1999 |
|
15 |
15 |
$225.00 |
| D9986 |
|
265 |
253 |
$0.00 |