| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,190 |
6,183 |
$334K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,696 |
2,129 |
$299K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,282 |
894 |
$239K |
| D2934 |
|
589 |
164 |
$185K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,579 |
3,578 |
$170K |
| D1110 |
Prophylaxis - adult |
1,691 |
1,691 |
$139K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,616 |
1,541 |
$105K |
| D0140 |
Limited oral evaluation - problem focused |
1,824 |
1,799 |
$63K |
| D0330 |
Panoramic radiographic image |
850 |
850 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,236 |
1,005 |
$48K |
| D1351 |
Sealant - per tooth |
10,169 |
1,964 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
135 |
107 |
$32K |
| D1510 |
|
118 |
83 |
$26K |
| D2331 |
|
397 |
258 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,855 |
2,641 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
4,432 |
4,427 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
782 |
432 |
$2K |
| D1206 |
Topical application of fluoride varnish |
6,498 |
6,490 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,516 |
5,124 |
$783.48 |
| D0272 |
Bitewings - two radiographic images |
3,361 |
3,356 |
$653.18 |
| D1354 |
|
549 |
137 |
$646.00 |
| D0220 |
Intraoral - periapical first radiographic image |
6,164 |
6,044 |
$617.44 |
| D0274 |
Bitewings - four radiographic images |
1,088 |
1,088 |
$538.44 |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$96.50 |
| D0270 |
|
42 |
42 |
$0.00 |
| D9986 |
|
65 |
61 |
$0.00 |