| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
21,954 |
21,912 |
$693K |
| D0274 |
Bitewings - four radiographic images |
14,296 |
14,272 |
$418K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,777 |
10,769 |
$374K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,793 |
1,212 |
$329K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,822 |
16,788 |
$301K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,097 |
2,718 |
$301K |
| D0120 |
Periodic oral evaluation - established patient |
11,871 |
11,840 |
$268K |
| D1351 |
Sealant - per tooth |
9,483 |
3,148 |
$226K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,905 |
5,743 |
$160K |
| D0220 |
Intraoral - periapical first radiographic image |
12,411 |
12,311 |
$140K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,360 |
9,531 |
$121K |
| D1206 |
Topical application of fluoride varnish |
5,385 |
5,374 |
$100K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,378 |
754 |
$91K |
| D0272 |
Bitewings - two radiographic images |
4,230 |
4,220 |
$86K |
| 99406 |
|
6,571 |
6,565 |
$86K |
| D0240 |
|
5,938 |
4,850 |
$72K |
| D0330 |
Panoramic radiographic image |
1,165 |
1,164 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,019 |
995 |
$30K |
| D9920 |
|
279 |
264 |
$28K |
| D9420 |
|
104 |
102 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
43 |
$5K |
| D1110 |
Prophylaxis - adult |
116 |
116 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
24 |
$2K |
| D0603 |
|
1,897 |
1,885 |
$0.00 |
| D0601 |
|
47 |
47 |
$0.00 |
| D1999 |
|
54 |
46 |
$0.00 |