| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,940 |
6,933 |
$308K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,394 |
640 |
$210K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,695 |
1,036 |
$140K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,204 |
1,203 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,747 |
1,746 |
$82K |
| D0210 |
Intraoral - complete series of radiographic images |
853 |
849 |
$81K |
| D1110 |
Prophylaxis - adult |
966 |
966 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,382 |
883 |
$71K |
| D0140 |
Limited oral evaluation - problem focused |
1,860 |
1,774 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
813 |
412 |
$28K |
| D0330 |
Panoramic radiographic image |
786 |
785 |
$22K |
| D1351 |
Sealant - per tooth |
4,996 |
1,039 |
$21K |
| D2332 |
|
18 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
7,462 |
7,455 |
$1K |
| D0274 |
Bitewings - four radiographic images |
817 |
817 |
$739.85 |
| D0120 |
Periodic oral evaluation - established patient |
4,890 |
4,886 |
$456.29 |
| D0220 |
Intraoral - periapical first radiographic image |
5,540 |
5,391 |
$413.19 |
| D0272 |
Bitewings - two radiographic images |
4,327 |
4,321 |
$286.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,698 |
4,443 |
$252.52 |
| D9420 |
|
241 |
241 |
$92.27 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,542 |
2,330 |
$16.42 |
| D0240 |
|
178 |
90 |
$0.00 |
| D1999 |
|
1,084 |
1,051 |
$0.00 |
| D9986 |
|
13 |
13 |
$0.00 |