| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,330 |
1,300 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
770 |
756 |
$74K |
| D0330 |
Panoramic radiographic image |
311 |
311 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
406 |
222 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
90 |
39 |
$20K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
125 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
353 |
161 |
$14K |
| D1351 |
Sealant - per tooth |
1,120 |
330 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
512 |
439 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
124 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
217 |
204 |
$6K |
| D9248 |
|
16 |
14 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$2K |
| D0190 |
|
360 |
242 |
$959.00 |
| D1330 |
|
1,094 |
953 |
$904.00 |
| D0120 |
Periodic oral evaluation - established patient |
888 |
866 |
$689.00 |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$560.00 |
| D1354 |
|
111 |
44 |
$546.90 |
| D0220 |
Intraoral - periapical first radiographic image |
828 |
790 |
$488.00 |
| D0603 |
|
279 |
274 |
$267.00 |
| D0602 |
|
230 |
228 |
$218.00 |
| D0272 |
Bitewings - two radiographic images |
986 |
959 |
$217.00 |
| D0601 |
|
204 |
202 |
$192.00 |
| D0240 |
|
599 |
313 |
$189.00 |
| D1206 |
Topical application of fluoride varnish |
1,433 |
1,401 |
$185.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
714 |
594 |
$0.00 |