| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,421 |
3,364 |
$167K |
| D1110 |
Prophylaxis - adult |
1,343 |
1,323 |
$86K |
| D1351 |
Sealant - per tooth |
3,722 |
969 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
422 |
$29K |
| D1120 |
Prophylaxis - child |
2,555 |
2,525 |
$28K |
| D9920 |
|
292 |
272 |
$24K |
| D9999 |
Unspecified adjunctive procedure, by report |
158 |
147 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
378 |
182 |
$13K |
| D0330 |
Panoramic radiographic image |
216 |
215 |
$10K |
| D8670 |
Periodic orthodontic treatment visit |
123 |
122 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
82 |
81 |
$5K |
| D1330 |
|
4,071 |
4,007 |
$5K |
| D0272 |
Bitewings - two radiographic images |
2,081 |
2,059 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
69 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,328 |
1,314 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,076 |
4,012 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
955 |
933 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$922.52 |
| D0601 |
|
736 |
581 |
$763.50 |
| D0999 |
Unspecified diagnostic procedure, by report |
29 |
29 |
$580.00 |
| D0602 |
|
67 |
57 |
$79.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
522 |
507 |
$4.00 |