| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,521 |
3,230 |
$165K |
| D1110 |
Prophylaxis - adult |
971 |
897 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
833 |
404 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,539 |
3,537 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
534 |
480 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
553 |
272 |
$25K |
| D9920 |
|
451 |
377 |
$25K |
| D1351 |
Sealant - per tooth |
2,434 |
550 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
592 |
305 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
125 |
75 |
$14K |
| D1120 |
Prophylaxis - child |
3,630 |
3,286 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
4,057 |
3,677 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,122 |
889 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
527 |
462 |
$6K |
| D0330 |
Panoramic radiographic image |
176 |
146 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
446 |
372 |
$4K |
| D2335 |
|
29 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,189 |
1,107 |
$1K |
| D1206 |
Topical application of fluoride varnish |
3,407 |
3,072 |
$946.98 |
| D0272 |
Bitewings - two radiographic images |
644 |
633 |
$690.32 |
| D0274 |
Bitewings - four radiographic images |
170 |
170 |
$461.24 |
| D1330 |
|
4,314 |
3,892 |
$382.16 |
| D9994 |
|
202 |
202 |
$215.20 |
| D0240 |
|
21 |
21 |
$0.00 |