| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,828 |
695 |
$120K |
| D1120 |
Prophylaxis - child |
2,115 |
2,096 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
1,070 |
1,067 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,022 |
1,005 |
$68K |
| D1310 |
|
898 |
886 |
$40K |
| D1351 |
Sealant - per tooth |
1,047 |
305 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
855 |
804 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
570 |
333 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,216 |
1,474 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,326 |
1,310 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
270 |
116 |
$21K |
| D1206 |
Topical application of fluoride varnish |
729 |
725 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
358 |
350 |
$17K |
| D0603 |
|
897 |
885 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
174 |
172 |
$12K |
| D0350 |
|
1,193 |
586 |
$11K |
| D0272 |
Bitewings - two radiographic images |
710 |
699 |
$8K |
| D9430 |
|
243 |
229 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
56 |
$6K |
| D0274 |
Bitewings - four radiographic images |
221 |
221 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
301 |
296 |
$4K |
| D1320 |
|
212 |
211 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
58 |
$955.00 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$630.00 |
| D0340 |
|
29 |
29 |
$350.00 |
| D1330 |
|
73 |
73 |
$0.00 |