| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,454 |
4,342 |
$104K |
| D1120 |
Prophylaxis - child |
3,054 |
2,986 |
$98K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,932 |
4,816 |
$97K |
| D1110 |
Prophylaxis - adult |
2,328 |
2,288 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,035 |
675 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,681 |
1,598 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
779 |
572 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,618 |
1,604 |
$42K |
| D0330 |
Panoramic radiographic image |
521 |
514 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,081 |
1,062 |
$18K |
| D1351 |
Sealant - per tooth |
638 |
267 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
297 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
604 |
548 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
99 |
62 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
25 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
38 |
$2K |
| D1206 |
Topical application of fluoride varnish |
82 |
80 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
24 |
$259.24 |
| D1999 |
|
21 |
21 |
$0.00 |