| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,005 |
4,004 |
$206K |
| D1206 |
Topical application of fluoride varnish |
3,996 |
3,995 |
$136K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,668 |
1,041 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
1,962 |
1,961 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,345 |
1,344 |
$84K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,292 |
3,342 |
$78K |
| D1351 |
Sealant - per tooth |
1,769 |
618 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
747 |
701 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
421 |
276 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,840 |
1,840 |
$22K |
| D0274 |
Bitewings - four radiographic images |
614 |
614 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
54 |
$5K |
| D9999 |
Unspecified adjunctive procedure, by report |
37 |
27 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
42 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
98 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D0603 |
|
632 |
632 |
$438.00 |
| D1310 |
|
324 |
324 |
$322.00 |
| D0601 |
|
664 |
664 |
$237.00 |
| D0602 |
|
125 |
125 |
$90.00 |