| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,669 |
3,669 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,214 |
681 |
$85K |
| D1120 |
Prophylaxis - child |
2,134 |
2,134 |
$62K |
| D1110 |
Prophylaxis - adult |
1,472 |
1,472 |
$53K |
| D1351 |
Sealant - per tooth |
1,809 |
426 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
527 |
325 |
$34K |
| D0330 |
Panoramic radiographic image |
853 |
853 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,026 |
1,026 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,600 |
1,600 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,551 |
1,551 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,914 |
2,889 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,473 |
2,463 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
104 |
73 |
$8K |
| D0272 |
Bitewings - two radiographic images |
482 |
482 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
186 |
$3K |
| D0277 |
|
68 |
68 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
53 |
$891.00 |
| D1330 |
|
740 |
737 |
$0.00 |