| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,778 |
4,580 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
7,796 |
7,476 |
$133K |
| D9999 |
Unspecified adjunctive procedure, by report |
819 |
729 |
$96K |
| D1120 |
Prophylaxis - child |
4,448 |
4,260 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,634 |
5,398 |
$89K |
| D1351 |
Sealant - per tooth |
2,438 |
659 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,244 |
1,179 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,424 |
2,329 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,655 |
1,409 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,125 |
1,084 |
$21K |
| D0330 |
Panoramic radiographic image |
427 |
379 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
260 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
118 |
93 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,757 |
1,682 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
56 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
59 |
39 |
$3K |
| D2931 |
|
23 |
15 |
$3K |
| D1206 |
Topical application of fluoride varnish |
1,887 |
1,845 |
$2K |
| D2332 |
|
22 |
12 |
$2K |
| D2331 |
|
24 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
72 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
168 |
163 |
$518.10 |
| D1330 |
|
1,116 |
986 |
$0.00 |