| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,935 |
2,740 |
$92K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
557 |
133 |
$74K |
| D1120 |
Prophylaxis - child |
3,238 |
2,984 |
$74K |
| D1206 |
Topical application of fluoride varnish |
2,304 |
2,197 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
360 |
259 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,140 |
1,057 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
315 |
233 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,178 |
1,094 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
179 |
93 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
443 |
382 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
714 |
646 |
$8K |
| D0330 |
Panoramic radiographic image |
144 |
137 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
259 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$2K |
| D9248 |
|
16 |
15 |
$742.43 |
| D1351 |
Sealant - per tooth |
32 |
13 |
$718.14 |
| D0274 |
Bitewings - four radiographic images |
14 |
13 |
$198.30 |
| D0240 |
|
69 |
57 |
$150.00 |