| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,539 |
3,521 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
810 |
410 |
$76K |
| D1120 |
Prophylaxis - child |
2,587 |
2,572 |
$60K |
| D1206 |
Topical application of fluoride varnish |
3,723 |
3,690 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
578 |
329 |
$41K |
| D1110 |
Prophylaxis - adult |
1,160 |
1,153 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
252 |
66 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
397 |
195 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,287 |
1,282 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
431 |
424 |
$17K |
| D1351 |
Sealant - per tooth |
723 |
252 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
243 |
$3K |
| D9420 |
|
29 |
29 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
44 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$508.92 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
14 |
$489.16 |
| D9248 |
|
12 |
12 |
$0.00 |