| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
17,716 |
17,710 |
$1.36M |
| D1110 |
Prophylaxis - adult |
5,254 |
5,252 |
$594K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,236 |
2,140 |
$262K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,210 |
475 |
$132K |
| D0330 |
Panoramic radiographic image |
869 |
869 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
758 |
758 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,531 |
941 |
$64K |
| D7140 |
Extraction, erupted tooth or exposed root |
975 |
539 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
320 |
316 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
26 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
21,845 |
21,838 |
$6K |
| D1351 |
Sealant - per tooth |
10,815 |
2,536 |
$6K |
| D0274 |
Bitewings - four radiographic images |
4,623 |
4,621 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
20,858 |
20,729 |
$1K |
| D9248 |
|
64 |
63 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12,901 |
12,894 |
$994.22 |
| D1354 |
|
1,360 |
488 |
$765.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,251 |
19,605 |
$682.27 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,356 |
1,334 |
$217.36 |
| D1206 |
Topical application of fluoride varnish |
20,502 |
20,497 |
$216.80 |