| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,995 |
8,995 |
$631K |
| D1110 |
Prophylaxis - adult |
3,313 |
3,313 |
$349K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,437 |
1,705 |
$212K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,634 |
1,245 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,515 |
1,515 |
$103K |
| D0210 |
Intraoral - complete series of radiographic images |
622 |
621 |
$94K |
| D0330 |
Panoramic radiographic image |
1,233 |
1,233 |
$58K |
| D0145 |
Oral evaluation for a patient under three years of age |
373 |
373 |
$26K |
| D1351 |
Sealant - per tooth |
9,976 |
2,752 |
$16K |
| D9420 |
|
80 |
80 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
280 |
116 |
$13K |
| D0274 |
Bitewings - four radiographic images |
3,116 |
3,116 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
312 |
308 |
$9K |
| D1206 |
Topical application of fluoride varnish |
11,914 |
11,914 |
$5K |
| D1354 |
|
702 |
307 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,310 |
3,913 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
11,843 |
11,534 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
9,659 |
9,659 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
29 |
$875.03 |
| D7111 |
|
21 |
12 |
$692.36 |
| D0272 |
Bitewings - two radiographic images |
3,937 |
3,935 |
$177.38 |
| D1999 |
|
617 |
584 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30,292 |
10,722 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$0.00 |