| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,761 |
8,752 |
$559K |
| D1110 |
Prophylaxis - adult |
3,975 |
3,974 |
$417K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,671 |
824 |
$277K |
| D7240 |
Removal of impacted tooth - completely bony |
850 |
262 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,247 |
1,301 |
$160K |
| D0330 |
Panoramic radiographic image |
2,207 |
2,206 |
$157K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,087 |
2,087 |
$123K |
| D0210 |
Intraoral - complete series of radiographic images |
508 |
508 |
$97K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,095 |
700 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,049 |
500 |
$32K |
| D9420 |
|
380 |
380 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
843 |
821 |
$24K |
| D9310 |
|
627 |
627 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
231 |
231 |
$16K |
| D1351 |
Sealant - per tooth |
16,339 |
3,291 |
$9K |
| D0274 |
Bitewings - four radiographic images |
3,692 |
3,691 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
9,946 |
9,938 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12,187 |
12,178 |
$1K |
| D1354 |
|
876 |
316 |
$799.00 |
| D9239 |
|
442 |
439 |
$683.49 |
| D9243 |
|
1,248 |
441 |
$421.06 |
| D0272 |
Bitewings - two radiographic images |
6,535 |
6,522 |
$266.66 |
| D0220 |
Intraoral - periapical first radiographic image |
9,589 |
9,446 |
$183.45 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
251 |
117 |
$135.93 |
| D1999 |
|
17 |
17 |
$0.00 |
| D0240 |
|
44 |
43 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,889 |
2,612 |
$-189.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,222 |
8,544 |
$-1593.96 |