| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,298 |
15,294 |
$1.07M |
| D1110 |
Prophylaxis - adult |
5,652 |
5,646 |
$496K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,123 |
1,771 |
$415K |
| D9420 |
|
598 |
598 |
$359K |
| D0210 |
Intraoral - complete series of radiographic images |
2,116 |
2,116 |
$309K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,187 |
2,156 |
$300K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,961 |
2,074 |
$179K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,008 |
2,007 |
$128K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,780 |
1,497 |
$126K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,210 |
1,209 |
$83K |
| D0140 |
Limited oral evaluation - problem focused |
2,070 |
2,040 |
$54K |
| D1351 |
Sealant - per tooth |
18,010 |
3,787 |
$36K |
| D0330 |
Panoramic radiographic image |
2,292 |
2,290 |
$24K |
| D0274 |
Bitewings - four radiographic images |
5,322 |
5,313 |
$12K |
| D9248 |
|
178 |
171 |
$9K |
| D1354 |
|
2,438 |
956 |
$8K |
| D1206 |
Topical application of fluoride varnish |
20,437 |
20,425 |
$6K |
| D7111 |
|
85 |
65 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,800 |
5,509 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
17,793 |
17,783 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
17,865 |
17,614 |
$618.00 |
| D0272 |
Bitewings - two radiographic images |
9,982 |
9,979 |
$436.78 |
| D9920 |
|
30 |
29 |
$21.83 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
255 |
94 |
$0.00 |
| D9986 |
|
285 |
278 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32,877 |
15,490 |
$-141.39 |