| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,572 |
4,502 |
$245K |
| D1110 |
Prophylaxis - adult |
2,764 |
2,704 |
$161K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,710 |
1,073 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,355 |
855 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,540 |
1,507 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
4,211 |
4,134 |
$29K |
| D0330 |
Panoramic radiographic image |
528 |
507 |
$25K |
| D1351 |
Sealant - per tooth |
2,893 |
801 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
96 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
38 |
$4K |
| D1206 |
Topical application of fluoride varnish |
6,998 |
6,872 |
$4K |
| D0274 |
Bitewings - four radiographic images |
3,033 |
2,961 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
598 |
526 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
6,509 |
6,353 |
$3K |
| D1330 |
|
7,008 |
6,882 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
273 |
249 |
$2K |
| D0272 |
Bitewings - two radiographic images |
3,147 |
3,100 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
32 |
25 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
55 |
55 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,388 |
6,244 |
$409.00 |
| D3120 |
|
116 |
86 |
$128.42 |
| D0603 |
|
12 |
12 |
$25.00 |