| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
14,029 |
13,558 |
$476K |
| D1120 |
Prophylaxis - child |
12,358 |
11,919 |
$417K |
| D0120 |
Periodic oral evaluation - established patient |
11,931 |
11,510 |
$379K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,585 |
1,663 |
$327K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,417 |
1,155 |
$186K |
| D1351 |
Sealant - per tooth |
6,738 |
2,001 |
$182K |
| D1110 |
Prophylaxis - adult |
3,303 |
3,199 |
$163K |
| D0272 |
Bitewings - two radiographic images |
9,820 |
9,481 |
$147K |
| D0330 |
Panoramic radiographic image |
2,255 |
2,193 |
$123K |
| D0220 |
Intraoral - periapical first radiographic image |
6,244 |
6,015 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,256 |
2,226 |
$79K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,126 |
2,947 |
$74K |
| D0274 |
Bitewings - four radiographic images |
3,317 |
3,177 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,610 |
3,361 |
$53K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
297 |
83 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
298 |
163 |
$21K |
| D1330 |
|
1,281 |
1,265 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
106 |
$5K |
| D9248 |
|
37 |
36 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$429.00 |
| D1310 |
|
12 |
12 |
$107.25 |
| D1999 |
|
69 |
69 |
$0.00 |