| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,830 |
4,047 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,967 |
1,626 |
$71K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,013 |
580 |
$57K |
| D1510 |
|
399 |
271 |
$48K |
| D1110 |
Prophylaxis - adult |
874 |
733 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,771 |
738 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
248 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
748 |
379 |
$8K |
| D1351 |
Sealant - per tooth |
2,634 |
648 |
$6K |
| D9310 |
|
452 |
421 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,004 |
1,499 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
884 |
754 |
$5K |
| D0330 |
Panoramic radiographic image |
155 |
125 |
$4K |
| D0240 |
|
2,509 |
1,705 |
$4K |
| D2330 |
|
326 |
144 |
$2K |
| D0999 |
Unspecified diagnostic procedure, by report |
59 |
59 |
$1K |
| D9920 |
|
91 |
70 |
$914.78 |
| D0120 |
Periodic oral evaluation - established patient |
3,511 |
2,944 |
$585.37 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,688 |
728 |
$298.41 |
| D0272 |
Bitewings - two radiographic images |
3,685 |
3,065 |
$265.69 |
| D0220 |
Intraoral - periapical first radiographic image |
1,796 |
1,517 |
$124.24 |
| D0274 |
Bitewings - four radiographic images |
666 |
564 |
$65.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
5,745 |
4,804 |
$41.62 |
| D1330 |
|
5,671 |
4,748 |
$6.00 |
| D0602 |
|
548 |
543 |
$3.00 |
| D0601 |
|
403 |
402 |
$3.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
262 |
262 |
$0.00 |
| D0603 |
|
920 |
912 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
193 |
176 |
$0.00 |
| D9986 |
|
565 |
551 |
$0.00 |
| D9987 |
|
12 |
12 |
$0.00 |