| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,645 |
13,645 |
$582K |
| D0120 |
Periodic oral evaluation - established patient |
13,753 |
13,753 |
$394K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,379 |
2,411 |
$354K |
| D1206 |
Topical application of fluoride varnish |
9,235 |
9,235 |
$276K |
| D1351 |
Sealant - per tooth |
3,894 |
1,510 |
$188K |
| D1110 |
Prophylaxis - adult |
2,538 |
2,538 |
$140K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,018 |
1,355 |
$111K |
| D0272 |
Bitewings - two radiographic images |
6,344 |
6,341 |
$108K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,147 |
6,147 |
$88K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,478 |
977 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,009 |
2,009 |
$61K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
314 |
197 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,881 |
2,859 |
$38K |
| D0240 |
|
1,600 |
1,175 |
$36K |
| D0330 |
Panoramic radiographic image |
706 |
705 |
$28K |
| D1354 |
|
794 |
164 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,299 |
1,196 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,364 |
1,363 |
$13K |
| D0274 |
Bitewings - four radiographic images |
332 |
332 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
516 |
515 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
234 |
234 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
49 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
32 |
24 |
$3K |
| D9986 |
|
232 |
232 |
$0.00 |
| D1999 |
|
87 |
82 |
$0.00 |