| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
945 |
945 |
$22K |
| D1120 |
Prophylaxis - child |
934 |
934 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
163 |
$16K |
| D1206 |
Topical application of fluoride varnish |
1,186 |
1,186 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
338 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
111 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
679 |
446 |
$9K |
| D1351 |
Sealant - per tooth |
413 |
133 |
$7K |
| D1110 |
Prophylaxis - adult |
222 |
222 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
221 |
219 |
$6K |
| D0272 |
Bitewings - two radiographic images |
360 |
360 |
$6K |
| D0330 |
Panoramic radiographic image |
153 |
153 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
558 |
556 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
14 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
39 |
$3K |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
50 |
$2K |