| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,405 |
1,403 |
$38K |
| D1351 |
Sealant - per tooth |
1,417 |
336 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,500 |
1,498 |
$28K |
| D1120 |
Prophylaxis - child |
834 |
834 |
$23K |
| D0330 |
Panoramic radiographic image |
377 |
376 |
$21K |
| D1110 |
Prophylaxis - adult |
674 |
672 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
249 |
221 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,471 |
1,457 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,462 |
1,443 |
$16K |
| D1330 |
|
1,504 |
1,501 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
112 |
$12K |
| D0274 |
Bitewings - four radiographic images |
700 |
698 |
$11K |
| D0272 |
Bitewings - two radiographic images |
743 |
743 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
149 |
82 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
18 |
$5K |
| D9920 |
|
138 |
137 |
$5K |
| D7111 |
|
50 |
25 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
52 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
20 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
38 |
$695.00 |
| D3120 |
|
25 |
20 |
$472.50 |
| D0603 |
|
17 |
17 |
$17.00 |
| D0602 |
|
17 |
15 |
$14.00 |
| D0601 |
|
14 |
14 |
$13.00 |