| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,598 |
2,523 |
$112K |
| D1110 |
Prophylaxis - adult |
1,282 |
1,275 |
$85K |
| D1120 |
Prophylaxis - child |
1,719 |
1,651 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
358 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
521 |
327 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
39 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
109 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
15 |
$2K |
| D1510 |
|
12 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
67 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,283 |
1,268 |
$689.77 |
| D0272 |
Bitewings - two radiographic images |
1,154 |
1,147 |
$437.10 |
| D0274 |
Bitewings - four radiographic images |
1,722 |
1,711 |
$382.62 |
| D0230 |
Intraoral - periapical each additional radiographic image |
948 |
939 |
$231.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,802 |
2,784 |
$215.54 |
| D1330 |
|
3,043 |
2,940 |
$192.38 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
44 |
$148.64 |
| D1206 |
Topical application of fluoride varnish |
96 |
16 |
$0.00 |