| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,675 |
4,593 |
$135K |
| D1120 |
Prophylaxis - child |
4,080 |
4,004 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
849 |
511 |
$74K |
| D1206 |
Topical application of fluoride varnish |
4,828 |
4,736 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,146 |
1,131 |
$63K |
| D1110 |
Prophylaxis - adult |
1,495 |
1,472 |
$60K |
| D1351 |
Sealant - per tooth |
3,330 |
748 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
488 |
255 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
471 |
330 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,723 |
1,697 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
240 |
70 |
$26K |
| D1354 |
|
863 |
310 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
915 |
826 |
$20K |
| D0330 |
Panoramic radiographic image |
394 |
386 |
$19K |
| D0274 |
Bitewings - four radiographic images |
646 |
628 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
901 |
819 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
157 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
400 |
253 |
$4K |
| D1330 |
|
67 |
66 |
$858.00 |
| D9310 |
|
17 |
17 |
$0.00 |