| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,777 |
9,777 |
$331K |
| D0120 |
Periodic oral evaluation - established patient |
9,122 |
9,122 |
$212K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,734 |
1,489 |
$171K |
| D1206 |
Topical application of fluoride varnish |
4,784 |
4,783 |
$127K |
| D1351 |
Sealant - per tooth |
2,201 |
746 |
$83K |
| D1110 |
Prophylaxis - adult |
1,817 |
1,817 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,443 |
6,443 |
$78K |
| D0272 |
Bitewings - two radiographic images |
4,980 |
4,979 |
$68K |
| D0220 |
Intraoral - periapical first radiographic image |
5,776 |
5,759 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,773 |
1,773 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
714 |
489 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,140 |
1,140 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
409 |
237 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,233 |
3,020 |
$19K |
| D1354 |
|
406 |
94 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
26 |
$4K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
25 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
108 |
108 |
$3K |
| D0603 |
|
402 |
402 |
$484.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$317.96 |
| D9990 |
|
49 |
49 |
$176.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
64 |
64 |
$0.00 |
| D0602 |
|
16 |
16 |
$0.00 |
| D1999 |
|
260 |
254 |
$0.00 |