| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,070 |
1,487 |
$37K |
| D1120 |
Prophylaxis - child |
5,238 |
5,143 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
6,446 |
6,306 |
$22K |
| D1206 |
Topical application of fluoride varnish |
6,461 |
6,342 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
7,329 |
7,153 |
$14K |
| D0274 |
Bitewings - four radiographic images |
3,718 |
3,659 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,053 |
6,755 |
$12K |
| D0272 |
Bitewings - two radiographic images |
2,619 |
2,568 |
$9K |
| D1110 |
Prophylaxis - adult |
1,745 |
1,718 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,949 |
1,732 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
355 |
$4K |
| D1351 |
Sealant - per tooth |
1,020 |
294 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
348 |
246 |
$4K |
| D0330 |
Panoramic radiographic image |
410 |
399 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
28 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
150 |
87 |
$761.58 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
12 |
$380.52 |
| D9248 |
|
27 |
24 |
$220.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$219.04 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$214.92 |
| D1320 |
|
12 |
12 |
$12.81 |
| D0601 |
|
741 |
731 |
$0.00 |
| D0602 |
|
81 |
81 |
$0.00 |
| D0603 |
|
153 |
149 |
$0.00 |