| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,213 |
6,115 |
$273K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,204 |
1,596 |
$180K |
| D1110 |
Prophylaxis - adult |
2,031 |
1,995 |
$148K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,684 |
2,652 |
$131K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,066 |
461 |
$131K |
| D1120 |
Prophylaxis - child |
6,837 |
6,750 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,334 |
2,170 |
$58K |
| D9920 |
|
737 |
721 |
$45K |
| D0330 |
Panoramic radiographic image |
823 |
808 |
$28K |
| D1206 |
Topical application of fluoride varnish |
5,598 |
5,528 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,767 |
8,403 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
96 |
71 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,151 |
682 |
$13K |
| D0274 |
Bitewings - four radiographic images |
3,081 |
3,028 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
8,921 |
8,763 |
$8K |
| D1351 |
Sealant - per tooth |
1,869 |
587 |
$8K |
| D1999 |
|
3,054 |
2,907 |
$7K |
| D1330 |
|
8,920 |
8,793 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
130 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
379 |
370 |
$5K |
| D0272 |
Bitewings - two radiographic images |
3,766 |
3,724 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
117 |
56 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
85 |
85 |
$2K |
| D3120 |
|
64 |
41 |
$276.04 |
| D1310 |
|
67 |
67 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,169 |
3,113 |
$0.00 |
| D9210 |
|
15 |
15 |
$0.00 |
| D9986 |
|
40 |
34 |
$0.00 |