| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,915 |
15,652 |
$113K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,486 |
1,103 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
14,850 |
14,676 |
$65K |
| D1206 |
Topical application of fluoride varnish |
17,366 |
17,089 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,992 |
14,059 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
16,999 |
16,590 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,245 |
1,745 |
$33K |
| D0272 |
Bitewings - two radiographic images |
10,319 |
10,163 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,149 |
2,089 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,468 |
1,332 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,537 |
700 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,147 |
413 |
$12K |
| D0274 |
Bitewings - four radiographic images |
2,170 |
2,116 |
$12K |
| D2934 |
|
596 |
147 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,142 |
2,947 |
$8K |
| D3230 |
|
563 |
138 |
$8K |
| D1351 |
Sealant - per tooth |
3,853 |
1,239 |
$8K |
| D0330 |
Panoramic radiographic image |
1,492 |
1,467 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
1,975 |
1,807 |
$7K |
| D1110 |
Prophylaxis - adult |
1,143 |
1,111 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
97 |
$4K |
| D2335 |
|
22 |
12 |
$914.67 |
| D1354 |
|
186 |
58 |
$748.75 |
| D0160 |
|
153 |
153 |
$725.66 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$282.58 |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$83.10 |
| D1999 |
|
5,036 |
4,059 |
$42.00 |
| D0603 |
|
5,068 |
4,872 |
$0.00 |
| D0602 |
|
50 |
46 |
$0.00 |
| D0601 |
|
63 |
60 |
$0.00 |