| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,085 |
409 |
$76K |
| D1351 |
Sealant - per tooth |
2,399 |
634 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,799 |
1,790 |
$37K |
| D1120 |
Prophylaxis - child |
1,142 |
1,138 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,071 |
1,064 |
$26K |
| D1110 |
Prophylaxis - adult |
652 |
643 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
224 |
77 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,804 |
1,793 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,057 |
2,042 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,951 |
1,929 |
$16K |
| D0272 |
Bitewings - two radiographic images |
830 |
829 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
118 |
118 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
290 |
285 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
28 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
39 |
$991.64 |
| D0603 |
|
2,159 |
2,145 |
$0.00 |
| D0602 |
|
56 |
55 |
$0.00 |