| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,338 |
5,933 |
$151K |
| D1110 |
Prophylaxis - adult |
3,957 |
3,502 |
$129K |
| D1120 |
Prophylaxis - child |
4,030 |
3,481 |
$94K |
| D1206 |
Topical application of fluoride varnish |
6,796 |
5,839 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
994 |
705 |
$74K |
| D1351 |
Sealant - per tooth |
2,687 |
568 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,741 |
3,033 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,458 |
1,198 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
260 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,944 |
2,200 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,749 |
1,421 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
538 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
455 |
324 |
$9K |
| D0330 |
Panoramic radiographic image |
72 |
62 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
27 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$493.05 |
| 99199 |
Unlisted special service, procedure or report |
72 |
72 |
$375.00 |
| D9996 |
|
875 |
507 |
$198.00 |
| D0350 |
|
203 |
165 |
$0.00 |