| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,924 |
6,087 |
$270K |
| D1206 |
Topical application of fluoride varnish |
6,854 |
6,030 |
$211K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,168 |
2,819 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,679 |
1,030 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
3,682 |
3,204 |
$71K |
| D0272 |
Bitewings - two radiographic images |
3,791 |
3,323 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
870 |
257 |
$55K |
| D1351 |
Sealant - per tooth |
2,426 |
645 |
$50K |
| D0274 |
Bitewings - four radiographic images |
2,011 |
1,799 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,151 |
1,640 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
929 |
605 |
$32K |
| D0330 |
Panoramic radiographic image |
923 |
818 |
$31K |
| D0350 |
|
2,994 |
184 |
$27K |
| D8660 |
|
634 |
468 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
516 |
277 |
$19K |
| D0603 |
|
6,658 |
5,870 |
$17K |
| D0240 |
|
1,328 |
638 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,094 |
938 |
$11K |
| D8691 |
|
319 |
135 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
271 |
250 |
$8K |
| D9420 |
|
176 |
152 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
891 |
691 |
$4K |
| D2331 |
|
51 |
25 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
38 |
$3K |
| D1999 |
|
118 |
118 |
$2K |
| D3120 |
|
143 |
72 |
$2K |
| D9310 |
|
38 |
24 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
116 |
116 |
$1K |
| D1330 |
|
6,293 |
5,630 |
$0.00 |
| D9215 |
|
37 |
29 |
$0.00 |