| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
911 |
396 |
$86K |
| D1110 |
Prophylaxis - adult |
1,367 |
1,343 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,589 |
2,553 |
$72K |
| D1120 |
Prophylaxis - child |
1,335 |
1,325 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,429 |
1,408 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,893 |
2,861 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,548 |
2,845 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,059 |
3,007 |
$35K |
| D1351 |
Sealant - per tooth |
1,253 |
270 |
$33K |
| D0350 |
|
1,539 |
1,509 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
145 |
$20K |
| D0272 |
Bitewings - two radiographic images |
821 |
807 |
$18K |
| D7240 |
Removal of impacted tooth - completely bony |
41 |
15 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
112 |
60 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
139 |
$5K |
| D0330 |
Panoramic radiographic image |
216 |
211 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
56 |
55 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$777.04 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$257.61 |
| D0603 |
|
3,168 |
3,127 |
$0.00 |
| D0602 |
|
503 |
494 |
$0.00 |