| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,435 |
5,153 |
$244K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,853 |
1,359 |
$198K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,305 |
1,270 |
$78K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
467 |
337 |
$55K |
| D9248 |
|
701 |
603 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,551 |
693 |
$48K |
| D0330 |
Panoramic radiographic image |
714 |
697 |
$34K |
| D1110 |
Prophylaxis - adult |
643 |
608 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
791 |
399 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
925 |
542 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,097 |
1,934 |
$16K |
| D0240 |
|
1,459 |
1,380 |
$14K |
| D1351 |
Sealant - per tooth |
2,265 |
677 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
516 |
489 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
70 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,306 |
2,192 |
$5K |
| D1510 |
|
26 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,713 |
5,427 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
5,106 |
4,821 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
3,031 |
2,853 |
$909.62 |
| D2330 |
|
15 |
12 |
$446.33 |
| D1330 |
|
5,993 |
5,685 |
$189.95 |
| D0272 |
Bitewings - two radiographic images |
3,688 |
3,510 |
$99.78 |
| D9986 |
|
490 |
462 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
54 |
51 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |