| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,543 |
16,222 |
$199K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,419 |
1,830 |
$116K |
| D1206 |
Topical application of fluoride varnish |
19,008 |
18,676 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
14,778 |
14,553 |
$112K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,136 |
11,283 |
$70K |
| D0272 |
Bitewings - two radiographic images |
8,960 |
8,771 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,509 |
3,397 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
12,715 |
12,399 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
933 |
348 |
$41K |
| D1110 |
Prophylaxis - adult |
1,673 |
1,651 |
$25K |
| D0330 |
Panoramic radiographic image |
1,539 |
1,499 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
380 |
170 |
$11K |
| D1351 |
Sealant - per tooth |
972 |
275 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
416 |
203 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,364 |
1,310 |
$8K |
| D0274 |
Bitewings - four radiographic images |
496 |
489 |
$5K |
| D1999 |
|
1,189 |
1,166 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
250 |
246 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
37 |
$698.43 |
| D1330 |
|
7,822 |
7,438 |
$24.76 |
| D0601 |
|
186 |
150 |
$0.00 |