| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,619 |
16,619 |
$783K |
| D0120 |
Periodic oral evaluation - established patient |
15,910 |
15,910 |
$507K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,543 |
1,804 |
$314K |
| D1206 |
Topical application of fluoride varnish |
6,508 |
6,507 |
$214K |
| D1351 |
Sealant - per tooth |
2,661 |
1,125 |
$166K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,561 |
10,561 |
$163K |
| D0272 |
Bitewings - two radiographic images |
7,747 |
7,745 |
$145K |
| D1110 |
Prophylaxis - adult |
1,309 |
1,309 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,761 |
1,761 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
792 |
637 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
2,912 |
2,906 |
$45K |
| D0240 |
|
1,263 |
1,263 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,215 |
1,182 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,469 |
1,469 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
125 |
$9K |
| D0330 |
Panoramic radiographic image |
161 |
161 |
$7K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
275 |
274 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
26 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
36 |
36 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$137.94 |
| D1999 |
|
327 |
326 |
$0.00 |