| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
29 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
109 |
103 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
562 |
519 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
26 |
$12K |
| D1351 |
Sealant - per tooth |
567 |
60 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
781 |
759 |
$11K |
| D1120 |
Prophylaxis - child |
275 |
246 |
$9K |
| D1110 |
Prophylaxis - adult |
178 |
171 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
870 |
623 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
764 |
700 |
$9K |
| D0274 |
Bitewings - four radiographic images |
196 |
176 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
68 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
86 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
48 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
41 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
12 |
$994.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$628.92 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$352.43 |
| D0350 |
|
22 |
22 |
$183.80 |
| D0603 |
|
1,312 |
1,248 |
$0.00 |
| D0602 |
|
53 |
52 |
$0.00 |
| D1330 |
|
12 |
12 |
$0.00 |