| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,142 |
547 |
$82K |
| D1120 |
Prophylaxis - child |
2,034 |
2,026 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,853 |
1,845 |
$47K |
| D1351 |
Sealant - per tooth |
1,073 |
218 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
477 |
280 |
$24K |
| D1110 |
Prophylaxis - adult |
581 |
581 |
$23K |
| D1206 |
Topical application of fluoride varnish |
678 |
671 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,571 |
1,571 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
664 |
612 |
$16K |
| D0274 |
Bitewings - four radiographic images |
731 |
731 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
250 |
163 |
$14K |
| D0330 |
Panoramic radiographic image |
258 |
258 |
$8K |
| D0272 |
Bitewings - two radiographic images |
660 |
660 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
242 |
$7K |
| D2331 |
|
62 |
34 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
505 |
502 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
304 |
303 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
144 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
115 |
$1K |
| D0601 |
|
78 |
78 |
$780.00 |
| D9110 |
|
12 |
12 |
$250.60 |
| D0602 |
|
61 |
61 |
$40.00 |
| D1999 |
|
157 |
151 |
$0.00 |
| D1330 |
|
243 |
243 |
$0.00 |