| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,566 |
10,554 |
$803K |
| D1110 |
Prophylaxis - adult |
3,432 |
3,431 |
$358K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,517 |
1,798 |
$239K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,393 |
2,137 |
$171K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,325 |
452 |
$138K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,589 |
868 |
$79K |
| D0330 |
Panoramic radiographic image |
1,188 |
1,188 |
$58K |
| D1351 |
Sealant - per tooth |
12,077 |
3,476 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
238 |
238 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
1,096 |
1,077 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
903 |
901 |
$26K |
| D1354 |
|
926 |
439 |
$4K |
| D0170 |
|
93 |
88 |
$3K |
| D0274 |
Bitewings - four radiographic images |
3,438 |
3,433 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
12,963 |
12,953 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,051 |
4,710 |
$1K |
| D2330 |
|
35 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
9,130 |
9,123 |
$820.63 |
| D1206 |
Topical application of fluoride varnish |
4,845 |
4,843 |
$481.03 |
| D9420 |
|
43 |
42 |
$475.17 |
| D0220 |
Intraoral - periapical first radiographic image |
8,080 |
7,897 |
$322.73 |
| D7111 |
|
23 |
13 |
$310.47 |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,892 |
5,649 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
8,053 |
8,045 |
$-210.41 |