| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
19,031 |
18,681 |
$842K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,964 |
3,289 |
$744K |
| D1351 |
Sealant - per tooth |
16,670 |
4,141 |
$573K |
| D1206 |
Topical application of fluoride varnish |
22,221 |
21,821 |
$551K |
| D0120 |
Periodic oral evaluation - established patient |
18,019 |
17,697 |
$539K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,422 |
2,568 |
$436K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,921 |
746 |
$302K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,929 |
1,138 |
$210K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,653 |
3,589 |
$192K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,261 |
6,849 |
$134K |
| D3120 |
|
3,734 |
1,555 |
$128K |
| D1110 |
Prophylaxis - adult |
1,971 |
1,941 |
$121K |
| D2940 |
|
2,412 |
768 |
$119K |
| D0272 |
Bitewings - two radiographic images |
7,704 |
7,544 |
$118K |
| D0330 |
Panoramic radiographic image |
1,725 |
1,694 |
$74K |
| D1330 |
|
7,882 |
7,723 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
800 |
776 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
165 |
124 |
$25K |
| D0274 |
Bitewings - four radiographic images |
997 |
989 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,064 |
2,014 |
$20K |
| D2330 |
|
100 |
50 |
$8K |
| D2335 |
|
47 |
24 |
$7K |
| D9248 |
|
26 |
26 |
$5K |
| D7961 |
|
76 |
76 |
$5K |
| D0240 |
|
363 |
356 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
367 |
$3K |
| D7962 |
|
30 |
30 |
$2K |
| D1510 |
|
12 |
12 |
$1K |
| D1354 |
|
17 |
12 |
$179.35 |