| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,436 |
5,233 |
$235K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,915 |
1,838 |
$127K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,268 |
442 |
$120K |
| D1110 |
Prophylaxis - adult |
1,396 |
1,352 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,698 |
6,457 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
4,560 |
4,411 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
511 |
347 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,367 |
664 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
813 |
468 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,016 |
1,662 |
$29K |
| D9999 |
Unspecified adjunctive procedure, by report |
676 |
676 |
$28K |
| D0330 |
Panoramic radiographic image |
298 |
284 |
$25K |
| D1510 |
|
95 |
66 |
$23K |
| D0272 |
Bitewings - two radiographic images |
4,367 |
4,214 |
$17K |
| D1351 |
Sealant - per tooth |
2,654 |
703 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
862 |
806 |
$13K |
| D0240 |
|
1,551 |
1,012 |
$9K |
| D9310 |
|
310 |
269 |
$9K |
| D1330 |
|
6,660 |
6,433 |
$7K |
| D0274 |
Bitewings - four radiographic images |
1,143 |
1,115 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
3,000 |
2,754 |
$4K |
| D2931 |
|
31 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,174 |
1,651 |
$3K |
| D2330 |
|
97 |
51 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
265 |
253 |
$2K |
| D2332 |
|
35 |
15 |
$1K |
| D2331 |
|
26 |
12 |
$595.00 |
| D0603 |
|
1,626 |
1,495 |
$428.00 |
| D0601 |
|
791 |
757 |
$332.00 |
| D0602 |
|
599 |
563 |
$244.00 |