| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,281 |
8,088 |
$416K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,098 |
1,723 |
$196K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,259 |
6,068 |
$166K |
| D0272 |
Bitewings - two radiographic images |
6,932 |
6,759 |
$107K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,024 |
1,311 |
$100K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,039 |
2,718 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,759 |
3,728 |
$92K |
| D1110 |
Prophylaxis - adult |
1,568 |
1,542 |
$80K |
| D1206 |
Topical application of fluoride varnish |
5,068 |
5,057 |
$74K |
| D0330 |
Panoramic radiographic image |
1,893 |
1,853 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,698 |
4,494 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
543 |
369 |
$60K |
| D1351 |
Sealant - per tooth |
2,763 |
941 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
819 |
458 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,564 |
1,476 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
71 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
219 |
$7K |
| D2332 |
|
78 |
44 |
$5K |
| D0274 |
Bitewings - four radiographic images |
159 |
157 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
394 |
330 |
$2K |
| D2330 |
|
34 |
27 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
13 |
$986.96 |
| D1330 |
|
163 |
162 |
$672.98 |
| D9986 |
|
51 |
24 |
$0.00 |