| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,778 |
1,548 |
$192K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,372 |
722 |
$135K |
| D1120 |
Prophylaxis - child |
3,045 |
3,026 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,886 |
4,844 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
4,607 |
4,553 |
$76K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,872 |
3,339 |
$58K |
| D1110 |
Prophylaxis - adult |
1,600 |
1,580 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
4,697 |
4,277 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
259 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
569 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
811 |
805 |
$15K |
| D8670 |
Periodic orthodontic treatment visit |
67 |
66 |
$12K |
| D0272 |
Bitewings - two radiographic images |
525 |
518 |
$10K |
| D1351 |
Sealant - per tooth |
255 |
109 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
366 |
324 |
$7K |
| D2394 |
|
48 |
28 |
$6K |
| D8660 |
|
27 |
27 |
$6K |
| D0274 |
Bitewings - four radiographic images |
221 |
215 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
25 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$472.36 |
| D9994 |
|
1,231 |
1,212 |
$398.12 |
| D2740 |
Crown - porcelain/ceramic |
17 |
12 |
$0.00 |