| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,529 |
6,444 |
$401K |
| D1110 |
Prophylaxis - adult |
1,682 |
1,666 |
$116K |
| D0210 |
Intraoral - complete series of radiographic images |
644 |
644 |
$86K |
| D0330 |
Panoramic radiographic image |
823 |
816 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,041 |
658 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
6,974 |
6,884 |
$62K |
| D9248 |
|
569 |
554 |
$54K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
496 |
178 |
$49K |
| D1351 |
Sealant - per tooth |
2,728 |
745 |
$23K |
| D1206 |
Topical application of fluoride varnish |
7,644 |
7,549 |
$18K |
| D0272 |
Bitewings - two radiographic images |
7,096 |
7,010 |
$17K |
| D0240 |
|
5,309 |
3,352 |
$14K |
| D1330 |
|
7,667 |
7,578 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
470 |
234 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
38 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,009 |
981 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
323 |
318 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
985 |
976 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,287 |
2,243 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
808 |
707 |
$1K |
| D0601 |
|
326 |
317 |
$0.00 |
| D0603 |
|
485 |
481 |
$0.00 |
| D0602 |
|
90 |
86 |
$0.00 |
| D3120 |
|
22 |
16 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
72 |
40 |
$0.00 |