| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
550 |
539 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
91 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
165 |
88 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
622 |
609 |
$6K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$3K |
| D1351 |
Sealant - per tooth |
195 |
55 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
592 |
581 |
$3K |
| D1354 |
|
211 |
67 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
43 |
$804.09 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$151.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
565 |
556 |
$0.00 |
| D1330 |
|
578 |
568 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
271 |
268 |
$0.00 |
| D1120 |
Prophylaxis - child |
414 |
404 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
243 |
239 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
82 |
80 |
$0.00 |
| D1110 |
Prophylaxis - adult |
162 |
161 |
$0.00 |