| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
21,582 |
21,175 |
$930K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,829 |
2,568 |
$918K |
| D0120 |
Periodic oral evaluation - established patient |
25,969 |
25,473 |
$762K |
| D1206 |
Topical application of fluoride varnish |
28,893 |
28,329 |
$710K |
| D1351 |
Sealant - per tooth |
18,265 |
3,571 |
$611K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,374 |
3,223 |
$538K |
| D1110 |
Prophylaxis - adult |
6,728 |
6,580 |
$397K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,623 |
1,486 |
$276K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,690 |
1,884 |
$254K |
| D0330 |
Panoramic radiographic image |
4,483 |
4,405 |
$190K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,794 |
2,728 |
$145K |
| D0272 |
Bitewings - two radiographic images |
8,456 |
8,267 |
$127K |
| D0140 |
Limited oral evaluation - problem focused |
2,890 |
2,802 |
$127K |
| D0274 |
Bitewings - four radiographic images |
4,961 |
4,872 |
$111K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
662 |
576 |
$100K |
| D1330 |
|
15,497 |
15,187 |
$93K |
| D3120 |
|
2,388 |
1,018 |
$82K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,319 |
2,995 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
1,966 |
1,898 |
$18K |
| D2335 |
|
90 |
27 |
$14K |
| D0240 |
|
222 |
220 |
$4K |
| D1517 |
|
13 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
95 |
$865.68 |