| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,258 |
8,976 |
$399K |
| D1206 |
Topical application of fluoride varnish |
10,130 |
9,874 |
$354K |
| D1351 |
Sealant - per tooth |
14,099 |
3,147 |
$297K |
| D0274 |
Bitewings - four radiographic images |
8,985 |
8,698 |
$196K |
| D0120 |
Periodic oral evaluation - established patient |
7,514 |
7,277 |
$181K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,372 |
10,669 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,651 |
2,596 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
6,254 |
5,998 |
$59K |
| D1110 |
Prophylaxis - adult |
1,175 |
1,146 |
$50K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
582 |
176 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
744 |
332 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,427 |
1,288 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
481 |
261 |
$23K |
| D0999 |
Unspecified diagnostic procedure, by report |
347 |
347 |
$10K |
| D9999 |
Unspecified adjunctive procedure, by report |
416 |
416 |
$7K |
| D9310 |
|
142 |
139 |
$6K |
| D0272 |
Bitewings - two radiographic images |
275 |
266 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
333 |
307 |
$3K |
| D1353 |
|
136 |
46 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
52 |
$2K |
| D1999 |
|
108 |
108 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
27 |
$2K |
| D9248 |
|
14 |
12 |
$1K |
| D1354 |
|
43 |
12 |
$426.03 |
| D1330 |
|
21 |
18 |
$0.00 |
| D9986 |
|
169 |
167 |
$0.00 |