| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,874 |
2,856 |
$144K |
| D0330 |
Panoramic radiographic image |
545 |
538 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
522 |
519 |
$28K |
| D0272 |
Bitewings - two radiographic images |
2,538 |
2,525 |
$27K |
| D1351 |
Sealant - per tooth |
2,354 |
534 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
179 |
$19K |
| D1110 |
Prophylaxis - adult |
1,295 |
1,285 |
$19K |
| D1120 |
Prophylaxis - child |
2,168 |
2,155 |
$9K |
| D1330 |
|
3,449 |
3,431 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
25 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,972 |
1,961 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
85 |
$6K |
| D9920 |
|
56 |
56 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
121 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
43 |
$3K |
| D1999 |
|
32 |
32 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
49 |
49 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
61 |
$784.00 |
| D0274 |
Bitewings - four radiographic images |
339 |
333 |
$197.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,074 |
1,046 |
$158.00 |
| D3120 |
|
27 |
14 |
$112.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
830 |
816 |
$48.00 |
| D0603 |
|
347 |
342 |
$45.00 |
| D0601 |
|
1,855 |
1,847 |
$25.00 |
| D1206 |
Topical application of fluoride varnish |
1,277 |
1,268 |
$16.00 |
| D9986 |
|
18 |
18 |
$0.00 |