| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,722 |
6,686 |
$357K |
| D1110 |
Prophylaxis - adult |
2,341 |
2,339 |
$195K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,258 |
1,393 |
$190K |
| D0330 |
Panoramic radiographic image |
1,250 |
1,238 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,074 |
2,057 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
654 |
459 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
253 |
82 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
181 |
181 |
$26K |
| D1351 |
Sealant - per tooth |
7,270 |
1,313 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
309 |
203 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
6,389 |
6,359 |
$11K |
| D0274 |
Bitewings - four radiographic images |
2,094 |
2,088 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
289 |
285 |
$8K |
| D0272 |
Bitewings - two radiographic images |
5,163 |
5,133 |
$4K |
| D1206 |
Topical application of fluoride varnish |
8,192 |
8,152 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,299 |
2,094 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
370 |
369 |
$908.88 |
| D0220 |
Intraoral - periapical first radiographic image |
733 |
693 |
$616.15 |
| D0240 |
|
449 |
259 |
$99.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
62 |
$90.00 |
| D9986 |
|
17 |
17 |
$0.00 |