| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
17,732 |
17,732 |
$838K |
| D0120 |
Periodic oral evaluation - established patient |
17,207 |
17,207 |
$549K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,108 |
2,980 |
$462K |
| D1206 |
Topical application of fluoride varnish |
8,018 |
8,016 |
$264K |
| D0272 |
Bitewings - two radiographic images |
10,337 |
10,337 |
$194K |
| D1351 |
Sealant - per tooth |
2,923 |
1,247 |
$180K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,638 |
11,638 |
$179K |
| D1110 |
Prophylaxis - adult |
2,713 |
2,713 |
$174K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,948 |
2,948 |
$98K |
| D0240 |
|
3,144 |
3,138 |
$95K |
| D0220 |
Intraoral - periapical first radiographic image |
5,331 |
5,319 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
705 |
570 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,227 |
1,227 |
$39K |
| D0330 |
Panoramic radiographic image |
845 |
845 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,499 |
1,466 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,053 |
2,052 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
99 |
89 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
90 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
38 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
446 |
444 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
93 |
93 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
102 |
$2K |
| D1354 |
|
41 |
12 |
$615.00 |
| D1999 |
|
255 |
251 |
$0.00 |