| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,933 |
1,925 |
$132K |
| D1120 |
Prophylaxis - child |
2,830 |
2,819 |
$119K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,102 |
1,097 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
900 |
563 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,360 |
1,195 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,735 |
2,724 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,403 |
1,824 |
$22K |
| D1351 |
Sealant - per tooth |
540 |
204 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,211 |
1,205 |
$14K |
| D0350 |
|
2,513 |
1,025 |
$13K |
| D0274 |
Bitewings - four radiographic images |
595 |
590 |
$10K |
| D0240 |
|
781 |
391 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
353 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
62 |
$5K |
| D1310 |
|
116 |
115 |
$4K |
| D0330 |
Panoramic radiographic image |
125 |
121 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
26 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |
| D0603 |
|
98 |
97 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$708.00 |
| D9430 |
|
17 |
17 |
$544.00 |
| D0601 |
|
26 |
25 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |