| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
662 |
661 |
$77K |
| D9420 |
|
61 |
60 |
$77K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
279 |
248 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
193 |
$27K |
| D1120 |
Prophylaxis - child |
1,015 |
1,009 |
$23K |
| D9995 |
|
573 |
544 |
$16K |
| D1110 |
Prophylaxis - adult |
172 |
172 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
137 |
$5K |
| D0330 |
Panoramic radiographic image |
103 |
103 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
287 |
124 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
69 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
183 |
54 |
$3K |
| D9920 |
|
73 |
68 |
$2K |
| D1999 |
|
27 |
27 |
$2K |
| D0240 |
|
207 |
206 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,034 |
1,015 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
698 |
694 |
$757.28 |
| D0603 |
|
587 |
571 |
$720.79 |
| D0274 |
Bitewings - four radiographic images |
172 |
172 |
$597.85 |
| D0601 |
|
350 |
335 |
$483.79 |
| D0230 |
Intraoral - periapical each additional radiographic image |
957 |
939 |
$432.83 |
| D1351 |
Sealant - per tooth |
355 |
105 |
$401.92 |
| D1330 |
|
1,211 |
1,205 |
$318.02 |
| D0191 |
|
15 |
15 |
$239.61 |
| D1354 |
|
448 |
119 |
$172.20 |
| D1206 |
Topical application of fluoride varnish |
1,192 |
1,186 |
$78.45 |
| D9999 |
Unspecified adjunctive procedure, by report |
28 |
28 |
$20.00 |
| D0602 |
|
68 |
68 |
$5.00 |
| D9992 |
|
205 |
190 |
$0.00 |