| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,928 |
4,902 |
$285K |
| D1120 |
Prophylaxis - child |
6,265 |
6,234 |
$242K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,400 |
1,291 |
$160K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,722 |
5,918 |
$128K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,389 |
6,357 |
$82K |
| D0272 |
Bitewings - two radiographic images |
5,349 |
5,322 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
864 |
863 |
$58K |
| D1352 |
|
1,406 |
444 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
178 |
$21K |
| D9430 |
|
439 |
418 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
987 |
958 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
267 |
247 |
$11K |
| D1351 |
Sealant - per tooth |
483 |
169 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
110 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
24 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$826.00 |
| D1999 |
|
22 |
22 |
$0.00 |