| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,424 |
3,411 |
$97K |
| D1120 |
Prophylaxis - child |
2,511 |
2,500 |
$90K |
| D1351 |
Sealant - per tooth |
3,275 |
878 |
$90K |
| D0145 |
Oral evaluation for a patient under three years of age |
557 |
552 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,717 |
3,702 |
$54K |
| D1110 |
Prophylaxis - adult |
977 |
973 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,167 |
2,158 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,964 |
3,916 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,890 |
3,650 |
$40K |
| D0274 |
Bitewings - four radiographic images |
965 |
962 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
155 |
$29K |
| D9248 |
|
176 |
168 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
260 |
170 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
94 |
52 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
167 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
344 |
334 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
186 |
$6K |
| D0330 |
Panoramic radiographic image |
417 |
416 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
71 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
170 |
167 |
$3K |
| D0603 |
|
4,563 |
4,539 |
$0.00 |