| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
18,745 |
17,605 |
$459K |
| D1120 |
Prophylaxis - child |
13,390 |
12,611 |
$346K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,071 |
2,966 |
$308K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,852 |
2,137 |
$289K |
| D1110 |
Prophylaxis - adult |
7,850 |
7,348 |
$282K |
| D1206 |
Topical application of fluoride varnish |
12,936 |
12,018 |
$192K |
| D1351 |
Sealant - per tooth |
5,176 |
1,325 |
$144K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,090 |
2,835 |
$130K |
| D0140 |
Limited oral evaluation - problem focused |
3,616 |
3,411 |
$126K |
| D0274 |
Bitewings - four radiographic images |
4,118 |
3,861 |
$124K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,938 |
2,804 |
$111K |
| D0272 |
Bitewings - two radiographic images |
5,577 |
5,259 |
$98K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,331 |
5,139 |
$91K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,367 |
786 |
$81K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
531 |
288 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
5,086 |
4,687 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,301 |
1,061 |
$26K |
| D0330 |
Panoramic radiographic image |
307 |
299 |
$17K |
| D2940 |
|
388 |
215 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
118 |
91 |
$15K |
| D2331 |
|
152 |
102 |
$11K |
| D2332 |
|
84 |
54 |
$7K |
| D2330 |
|
117 |
81 |
$6K |
| D2335 |
|
35 |
25 |
$4K |
| D0240 |
|
55 |
37 |
$947.16 |
| D4355 |
|
12 |
12 |
$887.64 |