| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,599 |
16,022 |
$715K |
| D0120 |
Periodic oral evaluation - established patient |
14,184 |
13,684 |
$463K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,085 |
15,522 |
$430K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,124 |
1,950 |
$421K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,619 |
604 |
$305K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,970 |
1,017 |
$210K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,158 |
1,289 |
$187K |
| D1351 |
Sealant - per tooth |
4,843 |
1,482 |
$178K |
| D0272 |
Bitewings - two radiographic images |
5,765 |
5,548 |
$171K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,450 |
2,380 |
$146K |
| D0330 |
Panoramic radiographic image |
1,257 |
1,201 |
$98K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,382 |
1,263 |
$74K |
| D0140 |
Limited oral evaluation - problem focused |
999 |
947 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
1,298 |
1,200 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
58 |
$12K |
| D0240 |
|
237 |
234 |
$5K |
| D1510 |
|
15 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
16 |
15 |
$426.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
12 |
$369.32 |
| D9248 |
|
586 |
550 |
$0.00 |
| D1999 |
|
268 |
257 |
$0.00 |