| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,791 |
1,787 |
$48K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
83 |
45 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
199 |
$25K |
| D1110 |
Prophylaxis - adult |
692 |
688 |
$25K |
| D0330 |
Panoramic radiographic image |
570 |
569 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
289 |
167 |
$20K |
| D1120 |
Prophylaxis - child |
773 |
772 |
$19K |
| D1206 |
Topical application of fluoride varnish |
737 |
736 |
$13K |
| D0274 |
Bitewings - four radiographic images |
713 |
713 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
214 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
290 |
287 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
821 |
807 |
$4K |
| D2950 |
|
97 |
45 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
192 |
189 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
45 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
76 |
75 |
$608.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
107 |
$558.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$221.00 |