| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,659 |
13,656 |
$1.07M |
| D1110 |
Prophylaxis - adult |
6,244 |
6,244 |
$629K |
| D0210 |
Intraoral - complete series of radiographic images |
2,262 |
2,262 |
$389K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,652 |
3,088 |
$384K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,701 |
1,132 |
$306K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,368 |
1,765 |
$133K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,826 |
1,825 |
$121K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,876 |
1,032 |
$89K |
| D2332 |
|
458 |
301 |
$80K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,104 |
1,104 |
$74K |
| D0274 |
Bitewings - four radiographic images |
6,350 |
6,350 |
$51K |
| D7111 |
|
733 |
495 |
$41K |
| D0330 |
Panoramic radiographic image |
2,507 |
2,506 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
183 |
164 |
$36K |
| D9420 |
|
571 |
571 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,116 |
1,093 |
$27K |
| D1351 |
Sealant - per tooth |
24,289 |
5,501 |
$27K |
| D2934 |
|
71 |
25 |
$23K |
| D4346 |
|
163 |
163 |
$22K |
| D2335 |
|
14 |
12 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,749 |
5,331 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
16,858 |
16,856 |
$1K |
| D1206 |
Topical application of fluoride varnish |
18,996 |
18,993 |
$1K |
| D2330 |
|
39 |
21 |
$809.01 |
| D0220 |
Intraoral - periapical first radiographic image |
19,554 |
19,415 |
$358.44 |
| D1354 |
|
24 |
12 |
$238.00 |
| D0272 |
Bitewings - two radiographic images |
6,395 |
6,394 |
$126.99 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,050 |
622 |
$85.28 |
| D9986 |
|
134 |
134 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43,902 |
18,396 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$0.00 |