| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,580 |
6,402 |
$292K |
| D1110 |
Prophylaxis - adult |
3,854 |
3,183 |
$134K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,427 |
1,334 |
$130K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,559 |
1,359 |
$116K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,962 |
7,381 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
7,295 |
5,899 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,334 |
3,915 |
$101K |
| D0330 |
Panoramic radiographic image |
2,071 |
1,856 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,350 |
2,136 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,612 |
2,352 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,242 |
925 |
$36K |
| D1351 |
Sealant - per tooth |
796 |
253 |
$13K |
| D1206 |
Topical application of fluoride varnish |
912 |
831 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
163 |
83 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
53 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
90 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
819 |
665 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
140 |
120 |
$3K |
| D1321 |
|
93 |
87 |
$939.60 |
| D9110 |
|
27 |
25 |
$531.24 |
| D1999 |
|
797 |
632 |
$0.00 |
| D0603 |
|
15 |
15 |
$0.00 |