| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,350 |
6,200 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,624 |
1,273 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
6,645 |
6,523 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,709 |
7,539 |
$68K |
| D0272 |
Bitewings - two radiographic images |
5,109 |
4,981 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
5,332 |
4,988 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,709 |
4,255 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
866 |
826 |
$21K |
| D0240 |
|
2,315 |
1,834 |
$20K |
| D1110 |
Prophylaxis - adult |
1,272 |
1,246 |
$20K |
| D9248 |
|
447 |
418 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
894 |
786 |
$8K |
| D1351 |
Sealant - per tooth |
780 |
188 |
$7K |
| D0274 |
Bitewings - four radiographic images |
239 |
236 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
38 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
64 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
100 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$754.60 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
25 |
$636.64 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
12 |
$325.32 |
| D9920 |
|
25 |
24 |
$267.66 |
| D2335 |
|
14 |
12 |
$161.29 |