| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,309 |
12,300 |
$1.08M |
| D1110 |
Prophylaxis - adult |
2,676 |
2,676 |
$296K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,510 |
2,237 |
$243K |
| D0330 |
Panoramic radiographic image |
1,054 |
1,053 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,767 |
1,279 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
14,817 |
14,807 |
$53K |
| D9420 |
|
105 |
104 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
609 |
386 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
570 |
218 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
759 |
748 |
$16K |
| D1351 |
Sealant - per tooth |
10,344 |
2,459 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,506 |
1,506 |
$8K |
| D2331 |
|
60 |
40 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13,190 |
13,116 |
$315.64 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,996 |
4,796 |
$313.08 |
| D0274 |
Bitewings - four radiographic images |
1,899 |
1,899 |
$276.34 |
| D0272 |
Bitewings - two radiographic images |
8,316 |
8,308 |
$262.94 |
| D1206 |
Topical application of fluoride varnish |
4,382 |
4,382 |
$29.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
10,688 |
10,680 |
$13.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,117 |
12,147 |
$8.19 |