| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,351 |
3,767 |
$51K |
| D1120 |
Prophylaxis - child |
3,198 |
2,773 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,377 |
3,817 |
$49K |
| D1110 |
Prophylaxis - adult |
1,395 |
1,229 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,269 |
1,958 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
793 |
427 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
670 |
376 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
971 |
779 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
284 |
123 |
$12K |
| D1351 |
Sealant - per tooth |
756 |
186 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
188 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
344 |
314 |
$5K |
| D0330 |
Panoramic radiographic image |
227 |
177 |
$3K |
| D1206 |
Topical application of fluoride varnish |
132 |
88 |
$2K |
| D0160 |
|
12 |
12 |
$997.80 |
| D0140 |
Limited oral evaluation - problem focused |
84 |
76 |
$984.51 |
| D0274 |
Bitewings - four radiographic images |
30 |
15 |
$981.24 |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
162 |
$779.11 |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
39 |
$556.28 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
60 |
35 |
$0.00 |