| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,720 |
1,720 |
$50K |
| D1110 |
Prophylaxis - adult |
792 |
792 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
447 |
284 |
$40K |
| D1120 |
Prophylaxis - child |
1,042 |
1,042 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,473 |
1,473 |
$33K |
| D1351 |
Sealant - per tooth |
883 |
272 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
311 |
191 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
279 |
173 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
244 |
244 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
439 |
420 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
371 |
$16K |
| D0272 |
Bitewings - two radiographic images |
557 |
557 |
$15K |
| D1206 |
Topical application of fluoride varnish |
476 |
476 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
244 |
$10K |
| D0274 |
Bitewings - four radiographic images |
258 |
258 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
330 |
$5K |
| D2330 |
|
48 |
28 |
$4K |
| D1330 |
|
104 |
104 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
45 |
45 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
60 |
$759.94 |