| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,061 |
4,053 |
$100K |
| D1351 |
Sealant - per tooth |
6,178 |
1,261 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
4,165 |
4,158 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,142 |
688 |
$70K |
| D1206 |
Topical application of fluoride varnish |
1,700 |
1,689 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
610 |
383 |
$25K |
| D1110 |
Prophylaxis - adult |
495 |
495 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,782 |
2,782 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
356 |
343 |
$8K |
| D1353 |
|
815 |
176 |
$8K |
| D0272 |
Bitewings - two radiographic images |
674 |
674 |
$8K |
| D0603 |
|
855 |
830 |
$8K |
| D0330 |
Panoramic radiographic image |
457 |
457 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,068 |
1,063 |
$6K |
| D0273 |
|
1,602 |
1,602 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
26 |
$5K |
| D0274 |
Bitewings - four radiographic images |
442 |
442 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
314 |
313 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
917 |
912 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
39 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
115 |
84 |
$2K |
| D0240 |
|
93 |
93 |
$2K |
| D0601 |
|
122 |
122 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0602 |
|
80 |
80 |
$800.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$565.00 |
| D1310 |
|
189 |
141 |
$0.00 |
| D1330 |
|
38 |
33 |
$0.00 |