| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,524 |
13,281 |
$588K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,460 |
1,244 |
$544K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,271 |
1,991 |
$516K |
| D1206 |
Topical application of fluoride varnish |
19,199 |
18,845 |
$476K |
| D0120 |
Periodic oral evaluation - established patient |
15,461 |
15,204 |
$458K |
| D1351 |
Sealant - per tooth |
11,141 |
2,280 |
$372K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,027 |
1,630 |
$329K |
| D1110 |
Prophylaxis - adult |
3,639 |
3,584 |
$222K |
| D0140 |
Limited oral evaluation - problem focused |
4,407 |
4,210 |
$194K |
| D9248 |
|
637 |
597 |
$117K |
| D0330 |
Panoramic radiographic image |
2,194 |
2,175 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
919 |
515 |
$89K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
541 |
296 |
$80K |
| D0272 |
Bitewings - two radiographic images |
4,753 |
4,670 |
$72K |
| D3120 |
|
2,044 |
755 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,137 |
1,102 |
$59K |
| D1330 |
|
7,010 |
6,949 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,212 |
1,115 |
$22K |
| D9310 |
|
417 |
415 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,358 |
1,307 |
$13K |
| D2940 |
|
142 |
57 |
$7K |
| D0240 |
|
277 |
272 |
$4K |
| D8660 |
|
26 |
26 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
30 |
30 |
$2K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
134 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$600.00 |
| D9420 |
|
28 |
28 |
$420.00 |