| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,259 |
3,255 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
1,811 |
1,809 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
897 |
897 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,260 |
2,458 |
$56K |
| D1310 |
|
1,146 |
1,145 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
570 |
306 |
$38K |
| D1206 |
Topical application of fluoride varnish |
968 |
968 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,037 |
2,035 |
$29K |
| D1351 |
Sealant - per tooth |
712 |
220 |
$27K |
| D0272 |
Bitewings - two radiographic images |
2,056 |
2,053 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
559 |
525 |
$22K |
| D0603 |
|
1,140 |
1,139 |
$17K |
| D0350 |
|
1,136 |
580 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
150 |
102 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
63 |
63 |
$5K |
| D9920 |
|
30 |
29 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
40 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
76 |
$912.00 |
| D9430 |
|
26 |
25 |
$832.00 |
| D1330 |
|
13 |
13 |
$0.00 |