| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,218 |
586 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,782 |
3,515 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,717 |
2,563 |
$77K |
| D1120 |
Prophylaxis - child |
3,199 |
2,981 |
$70K |
| D1351 |
Sealant - per tooth |
2,057 |
592 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,061 |
957 |
$38K |
| D1110 |
Prophylaxis - adult |
676 |
634 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
450 |
264 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
818 |
685 |
$19K |
| D9999 |
Unspecified adjunctive procedure, by report |
623 |
585 |
$18K |
| D0330 |
Panoramic radiographic image |
504 |
468 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,644 |
1,553 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
254 |
119 |
$13K |
| D0160 |
|
278 |
249 |
$10K |
| D0274 |
Bitewings - four radiographic images |
1,038 |
964 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
442 |
378 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,215 |
996 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
12 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,303 |
719 |
$3K |
| D1999 |
|
30 |
25 |
$10.00 |
| D3120 |
|
18 |
12 |
$0.00 |