| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,530 |
6,860 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
8,005 |
7,256 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,423 |
7,650 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,019 |
474 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
141 |
26 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,156 |
1,039 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
897 |
828 |
$20K |
| D0272 |
Bitewings - two radiographic images |
3,410 |
3,091 |
$19K |
| D1351 |
Sealant - per tooth |
2,100 |
532 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
152 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,142 |
1,057 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
612 |
530 |
$6K |
| D0601 |
|
5,583 |
5,024 |
$5K |
| D1354 |
|
1,334 |
406 |
$4K |
| D0330 |
Panoramic radiographic image |
161 |
150 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
17 |
$3K |
| D0240 |
|
268 |
127 |
$3K |
| D1999 |
|
350 |
330 |
$3K |
| D0602 |
|
2,888 |
2,628 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
338 |
140 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
56 |
55 |
$1K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$711.86 |
| D9992 |
|
26 |
21 |
$360.00 |
| D1330 |
|
5,085 |
4,366 |
$28.00 |
| D0191 |
|
1,194 |
1,135 |
$0.00 |
| D2940 |
|
18 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
432 |
328 |
$0.00 |
| D0603 |
|
112 |
107 |
$0.00 |
| D1310 |
|
16 |
16 |
$0.00 |