| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,602 |
10,594 |
$734K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,288 |
2,589 |
$345K |
| D1110 |
Prophylaxis - adult |
2,085 |
2,080 |
$208K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,313 |
1,242 |
$185K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,669 |
1,665 |
$139K |
| D9248 |
|
1,178 |
1,168 |
$133K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,935 |
1,762 |
$90K |
| D9420 |
|
263 |
263 |
$85K |
| D2934 |
|
157 |
41 |
$55K |
| D1351 |
Sealant - per tooth |
10,699 |
3,799 |
$55K |
| D0330 |
Panoramic radiographic image |
815 |
811 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
215 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
634 |
629 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
802 |
429 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
645 |
645 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
28 |
$11K |
| D1510 |
|
18 |
14 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,484 |
3,357 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
10,518 |
10,511 |
$6K |
| D0274 |
Bitewings - four radiographic images |
1,846 |
1,842 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
11,337 |
11,260 |
$1K |
| D1354 |
|
148 |
68 |
$357.00 |
| D0240 |
|
86 |
44 |
$320.37 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
536 |
157 |
$201.49 |
| D0272 |
Bitewings - two radiographic images |
5,897 |
5,892 |
$138.20 |
| D1206 |
Topical application of fluoride varnish |
11,412 |
11,403 |
$52.87 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$0.00 |
| D9995 |
|
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,026 |
10,783 |
$-462.46 |