| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,825 |
13,456 |
$622K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,474 |
1,369 |
$317K |
| D1110 |
Prophylaxis - adult |
4,098 |
4,002 |
$256K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,987 |
2,588 |
$228K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,284 |
2,229 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
15,607 |
15,192 |
$116K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,231 |
1,407 |
$93K |
| D0330 |
Panoramic radiographic image |
1,343 |
1,307 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,215 |
2,542 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
369 |
315 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,297 |
3,076 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
17,716 |
17,238 |
$42K |
| D1351 |
Sealant - per tooth |
4,429 |
1,207 |
$27K |
| D2335 |
|
196 |
80 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
1,220 |
1,155 |
$17K |
| D0272 |
Bitewings - two radiographic images |
7,542 |
7,379 |
$14K |
| D1330 |
|
17,684 |
17,219 |
$13K |
| D0274 |
Bitewings - four radiographic images |
3,842 |
3,748 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
787 |
432 |
$6K |
| D9310 |
|
260 |
242 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
3,394 |
3,267 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
135 |
135 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
94 |
$2K |
| D7111 |
|
25 |
16 |
$2K |
| D9110 |
|
18 |
17 |
$917.66 |
| D9920 |
|
180 |
178 |
$720.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
32 |
32 |
$640.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$0.00 |