| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,775 |
6,769 |
$512K |
| D1110 |
Prophylaxis - adult |
3,973 |
3,966 |
$381K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,311 |
1,523 |
$204K |
| D0330 |
Panoramic radiographic image |
1,016 |
1,016 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,648 |
1,170 |
$98K |
| D7140 |
Extraction, erupted tooth or exposed root |
667 |
350 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
399 |
105 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
185 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
200 |
199 |
$10K |
| D1351 |
Sealant - per tooth |
6,602 |
1,809 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
10,023 |
10,011 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
163 |
$4K |
| D1354 |
|
91 |
42 |
$510.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,088 |
3,843 |
$452.28 |
| D0274 |
Bitewings - four radiographic images |
3,284 |
3,279 |
$154.49 |
| D0220 |
Intraoral - periapical first radiographic image |
10,302 |
10,208 |
$137.43 |
| D1208 |
Topical application of fluoride, excluding varnish |
5,171 |
5,161 |
$88.64 |
| D1206 |
Topical application of fluoride varnish |
6,128 |
6,125 |
$13.55 |
| D0272 |
Bitewings - two radiographic images |
5,652 |
5,648 |
$0.00 |
| D1999 |
|
1,253 |
1,240 |
$0.00 |
| D9986 |
|
95 |
87 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,439 |
9,553 |
$-517.12 |