| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
808 |
786 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
241 |
234 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
247 |
84 |
$30K |
| D1110 |
Prophylaxis - adult |
269 |
265 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
71 |
$11K |
| D9248 |
|
163 |
157 |
$7K |
| D1351 |
Sealant - per tooth |
474 |
116 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
86 |
80 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
42 |
$717.15 |
| D1120 |
Prophylaxis - child |
615 |
592 |
$676.85 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
15 |
$301.42 |
| D7140 |
Extraction, erupted tooth or exposed root |
152 |
78 |
$195.13 |
| D0272 |
Bitewings - two radiographic images |
503 |
484 |
$82.08 |
| D0240 |
|
694 |
356 |
$57.08 |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
115 |
$21.42 |
| D1330 |
|
842 |
815 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
806 |
779 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
82 |
81 |
$0.00 |