| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
39,471 |
39,070 |
$1.24M |
| D0120 |
Periodic oral evaluation - established patient |
29,547 |
29,273 |
$947K |
| D1120 |
Prophylaxis - child |
22,942 |
22,740 |
$790K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,764 |
4,072 |
$634K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,306 |
1,681 |
$597K |
| D1351 |
Sealant - per tooth |
18,399 |
5,313 |
$501K |
| D1110 |
Prophylaxis - adult |
9,782 |
9,659 |
$484K |
| D8670 |
Periodic orthodontic treatment visit |
2,413 |
2,173 |
$359K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,378 |
2,608 |
$327K |
| D0272 |
Bitewings - two radiographic images |
14,153 |
14,013 |
$308K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,918 |
1,970 |
$279K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
10,896 |
10,489 |
$251K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,812 |
5,751 |
$201K |
| D0330 |
Panoramic radiographic image |
3,674 |
3,640 |
$198K |
| D9248 |
|
1,460 |
1,392 |
$150K |
| D9420 |
|
1,061 |
1,054 |
$145K |
| D0140 |
Limited oral evaluation - problem focused |
2,876 |
2,821 |
$124K |
| D0274 |
Bitewings - four radiographic images |
3,155 |
3,118 |
$105K |
| D3120 |
|
3,482 |
1,221 |
$89K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,684 |
1,673 |
$68K |
| D0220 |
Intraoral - periapical first radiographic image |
4,393 |
4,247 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,017 |
1,393 |
$64K |
| D0240 |
|
1,133 |
771 |
$23K |
| D2330 |
|
95 |
54 |
$8K |
| D2390 |
|
45 |
13 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
27 |
$7K |
| D1310 |
|
648 |
648 |
$6K |
| D2331 |
|
45 |
29 |
$5K |
| D1354 |
|
114 |
36 |
$3K |
| D1320 |
|
201 |
201 |
$2K |
| D0170 |
|
25 |
25 |
$750.00 |
| D0171 |
|
13 |
13 |
$249.08 |
| D9215 |
|
8,058 |
7,764 |
$0.00 |
| D9986 |
|
1,022 |
1,004 |
$0.00 |