| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,085 |
4,486 |
$205K |
| D0120 |
Periodic oral evaluation - established patient |
5,968 |
5,336 |
$165K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,950 |
4,374 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,844 |
1,258 |
$126K |
| D1351 |
Sealant - per tooth |
1,940 |
988 |
$119K |
| D0274 |
Bitewings - four radiographic images |
2,290 |
2,130 |
$40K |
| D1110 |
Prophylaxis - adult |
997 |
930 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
4,626 |
4,137 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,138 |
1,043 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,328 |
3,592 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
286 |
221 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
313 |
218 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,178 |
1,008 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
63 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
302 |
229 |
$8K |
| D9110 |
|
142 |
120 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
374 |
326 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
71 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$280.00 |
| D1999 |
|
76 |
54 |
$0.00 |
| D1330 |
|
18 |
13 |
$0.00 |