| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,762 |
6,881 |
$180K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,720 |
1,017 |
$172K |
| D1351 |
Sealant - per tooth |
5,928 |
1,586 |
$139K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,442 |
3,340 |
$137K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,635 |
999 |
$124K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,018 |
481 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
5,567 |
3,617 |
$78K |
| D1206 |
Topical application of fluoride varnish |
4,843 |
3,729 |
$78K |
| D0330 |
Panoramic radiographic image |
1,789 |
1,621 |
$69K |
| D0272 |
Bitewings - two radiographic images |
4,958 |
3,721 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,245 |
3,215 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,949 |
1,536 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,685 |
3,159 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
847 |
761 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,869 |
2,537 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
365 |
237 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
238 |
238 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
315 |
285 |
$9K |
| D1999 |
|
2,051 |
1,615 |
$0.00 |
| D1110 |
Prophylaxis - adult |
403 |
98 |
$0.00 |