| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,226 |
1,405 |
$300K |
| D1351 |
Sealant - per tooth |
6,703 |
1,433 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
5,740 |
5,624 |
$158K |
| D1110 |
Prophylaxis - adult |
2,774 |
2,729 |
$143K |
| D1120 |
Prophylaxis - child |
3,411 |
3,330 |
$117K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,747 |
6,600 |
$94K |
| D0274 |
Bitewings - four radiographic images |
2,701 |
2,658 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
6,156 |
6,009 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,908 |
5,679 |
$64K |
| D0145 |
Oral evaluation for a patient under three years of age |
430 |
426 |
$58K |
| D0272 |
Bitewings - two radiographic images |
2,693 |
2,625 |
$57K |
| D0350 |
|
3,069 |
2,978 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
417 |
238 |
$29K |
| D7240 |
Removal of impacted tooth - completely bony |
82 |
27 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
490 |
471 |
$16K |
| D0330 |
Panoramic radiographic image |
256 |
252 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
89 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
55 |
$1K |
| D0240 |
|
135 |
72 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$256.24 |
| D0603 |
|
7,107 |
6,955 |
$0.00 |
| D0602 |
|
513 |
507 |
$0.00 |
| D0601 |
|
26 |
26 |
$0.00 |