| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,380 |
1,705 |
$326K |
| D1351 |
Sealant - per tooth |
10,349 |
2,277 |
$267K |
| D0120 |
Periodic oral evaluation - established patient |
8,219 |
8,108 |
$228K |
| D1110 |
Prophylaxis - adult |
3,550 |
3,500 |
$186K |
| D1120 |
Prophylaxis - child |
5,121 |
5,053 |
$180K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,231 |
1,219 |
$170K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,330 |
9,207 |
$132K |
| D0274 |
Bitewings - four radiographic images |
3,971 |
3,913 |
$115K |
| D0272 |
Bitewings - two radiographic images |
4,048 |
4,000 |
$87K |
| D0350 |
|
4,848 |
4,779 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,061 |
653 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
5,696 |
5,541 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,213 |
4,181 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
729 |
718 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
803 |
711 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
264 |
102 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
178 |
124 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
87 |
37 |
$12K |
| D0330 |
Panoramic radiographic image |
483 |
477 |
$12K |
| D7240 |
Removal of impacted tooth - completely bony |
30 |
13 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
52 |
$920.22 |
| D2332 |
|
33 |
14 |
$884.41 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$847.68 |
| D9239 |
|
13 |
13 |
$741.52 |
| D9243 |
|
13 |
13 |
$556.14 |
| D9612 |
|
13 |
13 |
$465.79 |
| D0603 |
|
10,594 |
10,467 |
$0.00 |
| D0602 |
|
288 |
284 |
$0.00 |
| D0601 |
|
105 |
103 |
$0.00 |