| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,264 |
1,264 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
244 |
101 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
452 |
305 |
$19K |
| D1120 |
Prophylaxis - child |
873 |
873 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
311 |
311 |
$10K |
| D1110 |
Prophylaxis - adult |
434 |
434 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
462 |
435 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
661 |
661 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
300 |
$7K |
| D0274 |
Bitewings - four radiographic images |
468 |
468 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,176 |
1,171 |
$5K |
| D1206 |
Topical application of fluoride varnish |
267 |
267 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
951 |
950 |
$4K |
| D1351 |
Sealant - per tooth |
214 |
28 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
68 |
$3K |
| D0272 |
Bitewings - two radiographic images |
300 |
300 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
118 |
108 |
$2K |
| D0603 |
|
144 |
144 |
$2K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$1K |
| D0602 |
|
61 |
61 |
$640.50 |
| D0601 |
|
58 |
58 |
$496.50 |