| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
14,593 |
14,585 |
$1.04M |
| D1110 |
Prophylaxis - adult |
5,215 |
5,212 |
$489K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,886 |
2,513 |
$306K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,215 |
852 |
$195K |
| D0330 |
Panoramic radiographic image |
2,099 |
2,099 |
$181K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,060 |
1,520 |
$127K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,186 |
1,186 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,144 |
619 |
$37K |
| D1351 |
Sealant - per tooth |
8,714 |
1,831 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
149 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
428 |
423 |
$12K |
| D9420 |
|
97 |
94 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
16,595 |
16,584 |
$7K |
| D2331 |
|
59 |
40 |
$3K |
| D0274 |
Bitewings - four radiographic images |
3,821 |
3,819 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,745 |
5,387 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,095 |
1,094 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13,122 |
13,004 |
$653.21 |
| D0272 |
Bitewings - two radiographic images |
10,967 |
10,960 |
$53.02 |
| D1206 |
Topical application of fluoride varnish |
18,223 |
18,213 |
$27.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,603 |
11,387 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,207 |
1,206 |
$0.00 |
| D1999 |
|
2,458 |
2,447 |
$0.00 |