| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,387 |
6,381 |
$221K |
| D1110 |
Prophylaxis - adult |
6,064 |
6,058 |
$216K |
| D0120 |
Periodic oral evaluation - established patient |
8,494 |
8,491 |
$184K |
| D0274 |
Bitewings - four radiographic images |
6,607 |
6,603 |
$123K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,128 |
1,417 |
$123K |
| D1351 |
Sealant - per tooth |
2,783 |
1,045 |
$121K |
| D0220 |
Intraoral - periapical first radiographic image |
12,731 |
12,681 |
$118K |
| D1206 |
Topical application of fluoride varnish |
3,339 |
3,337 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,642 |
3,634 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,579 |
11,557 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,595 |
4,590 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,346 |
906 |
$53K |
| D0272 |
Bitewings - two radiographic images |
3,331 |
3,330 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
295 |
201 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
455 |
339 |
$18K |
| D1354 |
|
670 |
188 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
1,681 |
1,674 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
105 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
917 |
908 |
$9K |
| D0330 |
Panoramic radiographic image |
359 |
359 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
176 |
176 |
$4K |
| D1320 |
|
462 |
462 |
$3K |
| D4341 |
|
52 |
24 |
$2K |
| D9110 |
|
46 |
44 |
$793.96 |
| D9310 |
|
12 |
12 |
$576.51 |
| D9920 |
|
63 |
62 |
$463.88 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$360.00 |
| D1330 |
|
210 |
210 |
$0.00 |
| D1310 |
|
123 |
123 |
$0.00 |
| D9986 |
|
18 |
18 |
$0.00 |
| D1203 |
|
31 |
31 |
$0.00 |