| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,573 |
6,091 |
$322K |
| D1206 |
Topical application of fluoride varnish |
6,153 |
5,676 |
$274K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,577 |
3,292 |
$100K |
| D1351 |
Sealant - per tooth |
4,919 |
1,198 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,908 |
2,689 |
$82K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,384 |
667 |
$77K |
| D0272 |
Bitewings - two radiographic images |
3,435 |
3,137 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,056 |
5,996 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,792 |
4,425 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
677 |
244 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
4,204 |
3,665 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,530 |
1,419 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,292 |
1,651 |
$30K |
| D2160 |
|
360 |
214 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
759 |
589 |
$19K |
| D2140 |
|
415 |
226 |
$17K |
| D1354 |
|
1,738 |
374 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
613 |
278 |
$16K |
| D0603 |
|
3,700 |
3,623 |
$15K |
| D9630 |
|
2,117 |
1,522 |
$14K |
| D1353 |
|
723 |
227 |
$10K |
| D7111 |
|
89 |
64 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
12 |
$990.15 |
| D2330 |
|
31 |
13 |
$902.08 |
| D9420 |
|
49 |
23 |
$819.80 |
| D3120 |
|
133 |
59 |
$512.50 |
| D9215 |
|
1,891 |
1,276 |
$473.55 |
| D9991 |
|
15 |
15 |
$153.75 |