| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
17,760 |
17,545 |
$467K |
| D1120 |
Prophylaxis - child |
14,785 |
14,574 |
$406K |
| D1206 |
Topical application of fluoride varnish |
18,340 |
18,082 |
$298K |
| D1110 |
Prophylaxis - adult |
4,488 |
4,424 |
$172K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,840 |
3,596 |
$170K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,514 |
1,015 |
$160K |
| D0272 |
Bitewings - two radiographic images |
7,125 |
7,019 |
$120K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
745 |
168 |
$96K |
| D1351 |
Sealant - per tooth |
3,399 |
1,102 |
$91K |
| D0330 |
Panoramic radiographic image |
1,547 |
1,526 |
$76K |
| D0274 |
Bitewings - four radiographic images |
1,909 |
1,876 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
774 |
336 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
1,074 |
1,048 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,686 |
2,574 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
423 |
278 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
742 |
710 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,104 |
1,056 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
214 |
211 |
$4K |
| D9420 |
|
21 |
15 |
$990.00 |
| D0270 |
|
15 |
15 |
$21.58 |
| D9215 |
|
3,080 |
2,902 |
$0.00 |