| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,369 |
16,058 |
$173K |
| D0120 |
Periodic oral evaluation - established patient |
16,329 |
16,109 |
$109K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24,098 |
15,794 |
$105K |
| D1351 |
Sealant - per tooth |
9,887 |
2,814 |
$70K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,562 |
432 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
17,220 |
16,787 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,784 |
1,293 |
$64K |
| D1206 |
Topical application of fluoride varnish |
10,209 |
10,046 |
$63K |
| D0272 |
Bitewings - two radiographic images |
10,268 |
10,063 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,116 |
3,036 |
$40K |
| D1110 |
Prophylaxis - adult |
3,545 |
3,486 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,204 |
584 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,759 |
8,585 |
$35K |
| D0274 |
Bitewings - four radiographic images |
2,408 |
2,365 |
$20K |
| D0330 |
Panoramic radiographic image |
2,570 |
2,516 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
686 |
432 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,286 |
2,189 |
$13K |
| D1354 |
|
1,529 |
563 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
512 |
496 |
$6K |
| D0160 |
|
141 |
128 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
73 |
27 |
$2K |
| D2929 |
|
58 |
15 |
$866.00 |
| D3230 |
|
58 |
15 |
$684.62 |
| D9248 |
|
16 |
14 |
$200.89 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$133.75 |
| D1330 |
|
8,750 |
8,287 |
$0.00 |
| D0603 |
|
45 |
45 |
$0.00 |
| D0602 |
|
179 |
175 |
$0.00 |
| D0601 |
|
328 |
266 |
$0.00 |