| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
13 |
$817.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
329 |
$621.00 |
| D1120 |
Prophylaxis - child |
622 |
607 |
$528.00 |
| D1351 |
Sealant - per tooth |
198 |
45 |
$473.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$418.00 |
| D1206 |
Topical application of fluoride varnish |
522 |
507 |
$360.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
128 |
103 |
$250.00 |
| D9310 |
|
57 |
57 |
$210.00 |
| D0272 |
Bitewings - two radiographic images |
209 |
205 |
$95.00 |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
277 |
$68.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
257 |
245 |
$48.00 |
| D0330 |
Panoramic radiographic image |
36 |
29 |
$22.00 |
| D0602 |
|
181 |
180 |
$20.00 |
| D0603 |
|
88 |
86 |
$10.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
69 |
69 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$0.00 |