| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,363 |
810 |
$241K |
| D1351 |
Sealant - per tooth |
7,999 |
1,905 |
$215K |
| D1110 |
Prophylaxis - adult |
1,930 |
1,910 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
3,388 |
3,362 |
$96K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,124 |
653 |
$88K |
| D1120 |
Prophylaxis - child |
2,399 |
2,383 |
$86K |
| D0145 |
Oral evaluation for a patient under three years of age |
505 |
503 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,525 |
4,488 |
$65K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
427 |
167 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,616 |
1,602 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
670 |
667 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,352 |
1,342 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
768 |
762 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
615 |
563 |
$16K |
| D0350 |
|
752 |
741 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
307 |
$4K |
| D1330 |
|
45 |
45 |
$525.53 |
| D0160 |
|
25 |
25 |
$343.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
13 |
$172.65 |
| D0603 |
|
5,424 |
5,335 |
$0.00 |
| D0602 |
|
63 |
62 |
$0.00 |
| D0601 |
|
14 |
13 |
$0.00 |
| D9986 |
|
13 |
12 |
$0.00 |