| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,073 |
16,072 |
$634K |
| D0120 |
Periodic oral evaluation - established patient |
12,510 |
12,508 |
$295K |
| D1206 |
Topical application of fluoride varnish |
9,886 |
9,886 |
$291K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,337 |
1,666 |
$285K |
| D1351 |
Sealant - per tooth |
5,641 |
3,095 |
$259K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,084 |
2,384 |
$160K |
| D0272 |
Bitewings - two radiographic images |
11,559 |
11,556 |
$155K |
| D1354 |
|
11,337 |
4,382 |
$153K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,165 |
1,977 |
$152K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,238 |
1,932 |
$115K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,682 |
7,680 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,802 |
2,802 |
$78K |
| D0330 |
Panoramic radiographic image |
2,195 |
2,195 |
$75K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,119 |
5,000 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
3,472 |
3,443 |
$29K |
| D0145 |
Oral evaluation for a patient under three years of age |
764 |
764 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
1,928 |
1,918 |
$23K |
| D0240 |
|
961 |
960 |
$13K |
| D9920 |
|
249 |
242 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
407 |
407 |
$3K |
| D9997 |
|
50 |
49 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0270 |
|
40 |
40 |
$320.00 |
| D9990 |
|
13 |
13 |
$286.00 |
| D9215 |
|
2,285 |
2,238 |
$0.00 |
| D1330 |
|
7,808 |
7,808 |
$0.00 |
| D9630 |
|
1,858 |
1,853 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
303 |
299 |
$0.00 |
| D1999 |
|
40 |
40 |
$0.00 |