| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,855 |
632 |
$166K |
| D0145 |
Oral evaluation for a patient under three years of age |
923 |
917 |
$126K |
| D1351 |
Sealant - per tooth |
4,691 |
719 |
$120K |
| D1110 |
Prophylaxis - adult |
1,626 |
1,589 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,511 |
2,456 |
$68K |
| D1120 |
Prophylaxis - child |
1,790 |
1,749 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,854 |
1,799 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,008 |
2,938 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,451 |
3,356 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,173 |
1,118 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,538 |
3,113 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
469 |
448 |
$29K |
| D0272 |
Bitewings - two radiographic images |
997 |
981 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
157 |
27 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
132 |
$18K |
| D7240 |
Removal of impacted tooth - completely bony |
46 |
14 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
58 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
397 |
387 |
$8K |
| D9248 |
|
66 |
66 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
95 |
27 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
12 |
$6K |
| D1206 |
Topical application of fluoride varnish |
205 |
204 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
73 |
65 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$2K |
| D0160 |
|
111 |
110 |
$2K |
| D0350 |
|
119 |
118 |
$1K |
| D1330 |
|
111 |
110 |
$1K |
| D2950 |
|
23 |
16 |
$712.00 |
| D0603 |
|
1,229 |
1,211 |
$45.03 |
| D0602 |
|
1,718 |
1,686 |
$27.13 |
| D0601 |
|
1,609 |
1,585 |
$12.00 |
| D0431 |
|
15 |
14 |
$0.00 |