| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,694 |
840 |
$163K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,122 |
1,102 |
$153K |
| D1120 |
Prophylaxis - child |
4,348 |
4,234 |
$151K |
| D1351 |
Sealant - per tooth |
5,397 |
921 |
$137K |
| D1110 |
Prophylaxis - adult |
2,620 |
2,542 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
4,371 |
4,220 |
$119K |
| D1206 |
Topical application of fluoride varnish |
6,828 |
6,646 |
$96K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
887 |
459 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,062 |
3,810 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,931 |
1,856 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
4,397 |
4,169 |
$50K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
318 |
164 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,661 |
1,505 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,563 |
1,508 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
78 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
222 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
88 |
$6K |
| D0330 |
Panoramic radiographic image |
54 |
53 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$455.70 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$169.02 |
| D0603 |
|
5,722 |
5,610 |
$0.00 |
| D0602 |
|
167 |
166 |
$0.00 |
| D9986 |
|
79 |
79 |
$0.00 |