| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,218 |
898 |
$212K |
| D1351 |
Sealant - per tooth |
6,362 |
1,155 |
$168K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,057 |
1,053 |
$148K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,708 |
4,093 |
$87K |
| D1120 |
Prophylaxis - child |
2,406 |
2,359 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,515 |
2,470 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,253 |
2,201 |
$64K |
| D1110 |
Prophylaxis - adult |
1,092 |
1,071 |
$54K |
| D1206 |
Topical application of fluoride varnish |
3,674 |
3,607 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
4,405 |
4,265 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,381 |
1,345 |
$45K |
| D7240 |
Removal of impacted tooth - completely bony |
83 |
27 |
$24K |
| D0272 |
Bitewings - two radiographic images |
301 |
299 |
$7K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
95 |
43 |
$4K |
| D9222 |
|
43 |
43 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
74 |
65 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
15 |
$487.98 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
13 |
$176.40 |
| D0603 |
|
3,163 |
3,090 |
$0.00 |
| D0602 |
|
1,948 |
1,926 |
$0.00 |
| D0601 |
|
15 |
15 |
$0.00 |