| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,389 |
824 |
$270K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,256 |
785 |
$185K |
| D1351 |
Sealant - per tooth |
4,273 |
898 |
$180K |
| D1110 |
Prophylaxis - adult |
1,980 |
1,814 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
2,435 |
2,259 |
$98K |
| D1206 |
Topical application of fluoride varnish |
4,006 |
3,696 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,663 |
1,495 |
$91K |
| D1120 |
Prophylaxis - child |
1,422 |
1,362 |
$81K |
| D2740 |
Crown - porcelain/ceramic |
206 |
156 |
$79K |
| D0220 |
Intraoral - periapical first radiographic image |
2,914 |
2,693 |
$62K |
| D2394 |
|
258 |
188 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
1,001 |
916 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
782 |
673 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,009 |
940 |
$51K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
288 |
95 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,095 |
1,893 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
921 |
668 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
157 |
$24K |
| D4910 |
|
263 |
250 |
$23K |
| D0272 |
Bitewings - two radiographic images |
447 |
432 |
$16K |
| D2950 |
|
80 |
69 |
$14K |
| D2332 |
|
59 |
38 |
$10K |
| D0270 |
|
326 |
280 |
$6K |
| D2331 |
|
20 |
16 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
48 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
16 |
$461.76 |
| D0350 |
|
69 |
65 |
$0.00 |