| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,916 |
6,900 |
$248K |
| D0120 |
Periodic oral evaluation - established patient |
7,877 |
7,867 |
$193K |
| D1351 |
Sealant - per tooth |
4,165 |
1,068 |
$141K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,565 |
1,048 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,037 |
1,067 |
$90K |
| D0274 |
Bitewings - four radiographic images |
3,328 |
3,325 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,447 |
6,435 |
$80K |
| D1110 |
Prophylaxis - adult |
1,544 |
1,543 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
5,812 |
5,763 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,103 |
2,094 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
925 |
629 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,701 |
2,696 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
370 |
267 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,966 |
2,928 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
605 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
57 |
43 |
$5K |
| D0330 |
Panoramic radiographic image |
122 |
121 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
110 |
101 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
70 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
43 |
$1K |
| D0270 |
|
48 |
48 |
$522.97 |
| D1330 |
|
716 |
715 |
$120.00 |
| D1999 |
|
714 |
673 |
$0.00 |
| D0603 |
|
225 |
225 |
$0.00 |
| D1310 |
|
200 |
200 |
$0.00 |
| D0602 |
|
500 |
485 |
$0.00 |