| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,344 |
1,339 |
$89K |
| D1120 |
Prophylaxis - child |
2,019 |
2,010 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
402 |
$37K |
| D9420 |
|
103 |
102 |
$30K |
| D1351 |
Sealant - per tooth |
1,104 |
223 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
261 |
94 |
$14K |
| D0272 |
Bitewings - two radiographic images |
804 |
801 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
268 |
135 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
685 |
676 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
319 |
312 |
$9K |
| D9248 |
|
89 |
81 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
801 |
787 |
$7K |
| D1206 |
Topical application of fluoride varnish |
1,316 |
1,316 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
56 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
221 |
212 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,037 |
759 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
140 |
91 |
$4K |
| D3120 |
|
167 |
88 |
$3K |
| D0274 |
Bitewings - four radiographic images |
201 |
196 |
$3K |
| D0330 |
Panoramic radiographic image |
149 |
148 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
24 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$747.15 |
| D2140 |
|
24 |
14 |
$100.70 |