| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,240 |
5,152 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,421 |
4,349 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,211 |
695 |
$80K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
477 |
241 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
945 |
930 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,663 |
1,624 |
$43K |
| D0240 |
|
1,201 |
1,171 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
579 |
399 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,744 |
1,584 |
$18K |
| D0330 |
Panoramic radiographic image |
190 |
190 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
476 |
292 |
$13K |
| D1206 |
Topical application of fluoride varnish |
5,455 |
5,365 |
$13K |
| D1351 |
Sealant - per tooth |
2,222 |
582 |
$13K |
| D9420 |
|
17 |
17 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
574 |
558 |
$8K |
| D0272 |
Bitewings - two radiographic images |
2,746 |
2,702 |
$7K |
| D1110 |
Prophylaxis - adult |
93 |
92 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
2,053 |
2,001 |
$2K |
| D1330 |
|
5,425 |
5,333 |
$2K |
| D3120 |
|
68 |
29 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
45 |
45 |
$1K |
| D1354 |
|
265 |
126 |
$527.39 |
| D0274 |
Bitewings - four radiographic images |
322 |
318 |
$377.68 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$0.00 |
| D9995 |
|
23 |
23 |
$0.00 |