| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,681 |
8,506 |
$255K |
| D1120 |
Prophylaxis - child |
5,854 |
5,734 |
$254K |
| D1110 |
Prophylaxis - adult |
3,434 |
3,372 |
$206K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,091 |
704 |
$135K |
| D1206 |
Topical application of fluoride varnish |
5,222 |
5,126 |
$129K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,997 |
3,905 |
$87K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
349 |
232 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,995 |
1,955 |
$45K |
| D0330 |
Panoramic radiographic image |
985 |
964 |
$42K |
| D0272 |
Bitewings - two radiographic images |
2,325 |
2,266 |
$35K |
| D1351 |
Sealant - per tooth |
834 |
168 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,562 |
1,434 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
475 |
470 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
68 |
53 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
78 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
93 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
163 |
$1K |
| D3120 |
|
17 |
12 |
$595.00 |
| D0240 |
|
28 |
27 |
$252.00 |