| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,184 |
979 |
$9K |
| D1206 |
Topical application of fluoride varnish |
1,200 |
963 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
1,399 |
1,186 |
$6K |
| D1110 |
Prophylaxis - adult |
743 |
644 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
609 |
320 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
655 |
560 |
$5K |
| D2394 |
|
251 |
84 |
$4K |
| D1351 |
Sealant - per tooth |
927 |
170 |
$4K |
| D0274 |
Bitewings - four radiographic images |
323 |
285 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
244 |
143 |
$1K |
| D0272 |
Bitewings - two radiographic images |
314 |
274 |
$1K |
| D0240 |
|
376 |
197 |
$851.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
174 |
93 |
$617.92 |
| D0210 |
Intraoral - complete series of radiographic images |
400 |
356 |
$549.75 |
| D0140 |
Limited oral evaluation - problem focused |
245 |
226 |
$541.36 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
235 |
184 |
$464.25 |
| D0330 |
Panoramic radiographic image |
79 |
75 |
$451.64 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
269 |
177 |
$388.50 |
| D0220 |
Intraoral - periapical first radiographic image |
292 |
246 |
$286.21 |
| D1208 |
Topical application of fluoride, excluding varnish |
369 |
343 |
$223.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
80 |
$60.00 |
| D2335 |
|
38 |
13 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$0.00 |