| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,249 |
2,242 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,392 |
2,381 |
$47K |
| D1120 |
Prophylaxis - child |
1,590 |
1,589 |
$45K |
| D1351 |
Sealant - per tooth |
1,223 |
272 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
546 |
397 |
$33K |
| D1110 |
Prophylaxis - adult |
811 |
809 |
$30K |
| D0274 |
Bitewings - four radiographic images |
661 |
659 |
$20K |
| D0272 |
Bitewings - two radiographic images |
905 |
904 |
$16K |
| D0330 |
Panoramic radiographic image |
330 |
330 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
264 |
220 |
$13K |
| D0603 |
|
945 |
944 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
165 |
112 |
$8K |
| D1330 |
|
1,268 |
1,267 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
254 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
484 |
$4K |
| D0240 |
|
137 |
101 |
$2K |
| D1310 |
|
149 |
149 |
$2K |
| D0602 |
|
127 |
127 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
133 |
128 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$999.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$425.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$315.00 |