| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
799 |
791 |
$23K |
| D1120 |
Prophylaxis - child |
969 |
938 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
129 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
102 |
51 |
$14K |
| D1206 |
Topical application of fluoride varnish |
668 |
654 |
$12K |
| D1351 |
Sealant - per tooth |
697 |
228 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
333 |
314 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
58 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
51 |
$6K |
| D0274 |
Bitewings - four radiographic images |
236 |
228 |
$5K |
| D0272 |
Bitewings - two radiographic images |
265 |
259 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
113 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
287 |
$3K |
| D0330 |
Panoramic radiographic image |
133 |
125 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
87 |
82 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
164 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
50 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
66 |
$815.16 |