| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,615 |
5,409 |
$238K |
| D1206 |
Topical application of fluoride varnish |
5,771 |
5,621 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,216 |
716 |
$96K |
| D9248 |
|
1,089 |
967 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,786 |
3,704 |
$89K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,228 |
203 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,238 |
1,214 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,392 |
2,295 |
$40K |
| D1351 |
Sealant - per tooth |
1,290 |
364 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
782 |
266 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
819 |
129 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,548 |
1,383 |
$16K |
| D1110 |
Prophylaxis - adult |
326 |
318 |
$14K |
| D0274 |
Bitewings - four radiographic images |
799 |
668 |
$13K |
| D0330 |
Panoramic radiographic image |
305 |
299 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
345 |
312 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,683 |
1,259 |
$9K |
| D9420 |
|
318 |
174 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,427 |
1,264 |
$7K |
| D0999 |
Unspecified diagnostic procedure, by report |
174 |
174 |
$6K |
| D9999 |
Unspecified adjunctive procedure, by report |
220 |
209 |
$4K |
| D9310 |
|
86 |
86 |
$3K |
| D0350 |
|
376 |
272 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
38 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
104 |
104 |
$2K |
| D0703 |
|
89 |
85 |
$1K |
| D2330 |
|
17 |
14 |
$789.32 |
| D1999 |
|
59 |
48 |
$720.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
13 |
$112.64 |
| D9987 |
|
27 |
27 |
$0.00 |
| D9986 |
|
96 |
92 |
$0.00 |