| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,401 |
5,311 |
$275K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,755 |
3,713 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,749 |
5,653 |
$84K |
| D0330 |
Panoramic radiographic image |
1,635 |
1,611 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
882 |
531 |
$60K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
488 |
229 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,928 |
2,890 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,225 |
2,169 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,201 |
1,121 |
$44K |
| D1351 |
Sealant - per tooth |
2,090 |
538 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,095 |
1,075 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
628 |
428 |
$34K |
| D1110 |
Prophylaxis - adult |
490 |
482 |
$26K |
| D0274 |
Bitewings - four radiographic images |
613 |
606 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,649 |
1,624 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
234 |
138 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
940 |
485 |
$6K |
| D1354 |
|
53 |
16 |
$318.00 |
| D9987 |
|
340 |
301 |
$0.00 |
| D9986 |
|
607 |
523 |
$0.00 |
| D0603 |
|
44 |
44 |
$0.00 |