| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
994 |
994 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
370 |
256 |
$25K |
| D1120 |
Prophylaxis - child |
814 |
814 |
$24K |
| D1351 |
Sealant - per tooth |
689 |
153 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
869 |
869 |
$17K |
| D0272 |
Bitewings - two radiographic images |
848 |
847 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
422 |
412 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
153 |
$12K |
| D1110 |
Prophylaxis - adult |
283 |
283 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
81 |
69 |
$9K |
| D0603 |
|
894 |
894 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
78 |
$6K |
| D1330 |
|
939 |
939 |
$4K |
| D1206 |
Topical application of fluoride varnish |
182 |
182 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
152 |
$2K |
| D0330 |
Panoramic radiographic image |
23 |
23 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$384.00 |
| D0240 |
|
12 |
12 |
$316.80 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$264.00 |
| D0602 |
|
21 |
21 |
$210.00 |