| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,299 |
1,757 |
$324K |
| D0120 |
Periodic oral evaluation - established patient |
8,216 |
8,173 |
$231K |
| D1110 |
Prophylaxis - adult |
3,299 |
3,280 |
$176K |
| D1120 |
Prophylaxis - child |
4,899 |
4,876 |
$174K |
| D1351 |
Sealant - per tooth |
6,111 |
1,785 |
$166K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,553 |
8,349 |
$125K |
| D0145 |
Oral evaluation for a patient under three years of age |
911 |
905 |
$123K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,429 |
8,386 |
$120K |
| D0274 |
Bitewings - four radiographic images |
3,696 |
3,655 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,339 |
890 |
$100K |
| D0220 |
Intraoral - periapical first radiographic image |
8,928 |
8,805 |
$97K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
623 |
200 |
$85K |
| D0272 |
Bitewings - two radiographic images |
3,634 |
3,615 |
$73K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,606 |
2,443 |
$68K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
319 |
183 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
453 |
452 |
$23K |
| D0330 |
Panoramic radiographic image |
1,378 |
1,363 |
$21K |
| D9248 |
|
116 |
111 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
143 |
$3K |
| D0350 |
|
269 |
231 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
15 |
$897.16 |
| D0603 |
|
9,870 |
9,826 |
$0.00 |