| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,059 |
4,039 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,708 |
969 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,428 |
2,422 |
$55K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
481 |
211 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,081 |
4,059 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,121 |
485 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,930 |
1,708 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,425 |
1,424 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
1,284 |
1,260 |
$29K |
| D1351 |
Sealant - per tooth |
1,486 |
296 |
$25K |
| D3240 |
|
256 |
110 |
$19K |
| D0272 |
Bitewings - two radiographic images |
2,113 |
2,111 |
$17K |
| D9420 |
|
52 |
52 |
$16K |
| D9920 |
|
689 |
629 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,195 |
2,184 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
206 |
152 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,093 |
2,015 |
$8K |
| D0601 |
|
626 |
626 |
$6K |
| D0602 |
|
207 |
207 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
48 |
$2K |
| D0603 |
|
138 |
138 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$402.50 |
| D9999 |
Unspecified adjunctive procedure, by report |
52 |
52 |
$52.00 |
| D1999 |
|
1,004 |
877 |
$0.00 |