| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,060 |
2,772 |
$125K |
| D1206 |
Topical application of fluoride varnish |
3,015 |
2,762 |
$95K |
| D1351 |
Sealant - per tooth |
3,581 |
707 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,357 |
2,147 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
889 |
565 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,593 |
2,908 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,111 |
1,006 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
499 |
482 |
$27K |
| D0240 |
|
1,660 |
1,144 |
$26K |
| D1110 |
Prophylaxis - adult |
644 |
590 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
665 |
457 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,469 |
1,283 |
$25K |
| D0330 |
Panoramic radiographic image |
1,082 |
981 |
$21K |
| D0274 |
Bitewings - four radiographic images |
901 |
819 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,171 |
1,038 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,544 |
1,380 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
449 |
382 |
$12K |
| D0170 |
|
585 |
528 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
913 |
798 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
159 |
106 |
$6K |
| D9999 |
Unspecified adjunctive procedure, by report |
108 |
107 |
$5K |
| D1354 |
|
329 |
150 |
$3K |
| D0999 |
Unspecified diagnostic procedure, by report |
100 |
100 |
$3K |
| D1353 |
|
222 |
69 |
$3K |
| D8660 |
|
88 |
79 |
$2K |
| D0340 |
|
77 |
52 |
$2K |
| D3120 |
|
128 |
78 |
$2K |
| D0603 |
|
1,776 |
1,643 |
$1K |
| D0350 |
|
104 |
79 |
$943.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
12 |
$864.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
32 |
$525.22 |
| D9310 |
|
12 |
12 |
$462.00 |
| D9630 |
|
234 |
177 |
$388.52 |
| D0602 |
|
99 |
98 |
$86.00 |
| D0601 |
|
89 |
86 |
$68.00 |
| D9986 |
|
104 |
99 |
$0.00 |
| D0472 |
|
46 |
40 |
$0.00 |