| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,832 |
10,831 |
$253K |
| D1206 |
Topical application of fluoride varnish |
7,784 |
7,783 |
$219K |
| D1120 |
Prophylaxis - child |
6,536 |
6,536 |
$216K |
| D1110 |
Prophylaxis - adult |
4,360 |
4,360 |
$183K |
| D1351 |
Sealant - per tooth |
3,408 |
1,151 |
$128K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,140 |
725 |
$93K |
| D0274 |
Bitewings - four radiographic images |
3,480 |
3,480 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,305 |
3,305 |
$39K |
| D0330 |
Panoramic radiographic image |
797 |
797 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
406 |
223 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,359 |
1,359 |
$19K |
| D2394 |
|
128 |
102 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
92 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
568 |
563 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
79 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$4K |
| D2160 |
|
30 |
17 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
70 |
$932.45 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$656.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$176.24 |