| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,765 |
6,763 |
$369K |
| D0120 |
Periodic oral evaluation - established patient |
5,795 |
5,794 |
$193K |
| D1351 |
Sealant - per tooth |
7,343 |
1,474 |
$178K |
| D1206 |
Topical application of fluoride varnish |
4,973 |
4,972 |
$153K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,120 |
449 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,444 |
931 |
$100K |
| D0272 |
Bitewings - two radiographic images |
5,041 |
5,039 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,038 |
2,038 |
$60K |
| D0240 |
|
3,654 |
3,654 |
$47K |
| D0603 |
|
3,929 |
3,924 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
436 |
300 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
854 |
854 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
640 |
631 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
152 |
134 |
$16K |
| D9920 |
|
656 |
633 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,298 |
2,295 |
$16K |
| D9999 |
Unspecified adjunctive procedure, by report |
38 |
24 |
$13K |
| D0330 |
Panoramic radiographic image |
185 |
185 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,807 |
1,806 |
$9K |
| D1110 |
Prophylaxis - adult |
157 |
157 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
128 |
81 |
$8K |
| D0274 |
Bitewings - four radiographic images |
401 |
401 |
$6K |
| D0602 |
|
567 |
567 |
$6K |
| D2332 |
|
59 |
40 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
66 |
$3K |
| D9995 |
|
50 |
50 |
$1K |
| D0601 |
|
12 |
12 |
$100.00 |