| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,470 |
961 |
$243K |
| D1351 |
Sealant - per tooth |
4,151 |
986 |
$110K |
| D0145 |
Oral evaluation for a patient under three years of age |
551 |
543 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,438 |
2,418 |
$69K |
| D1120 |
Prophylaxis - child |
1,879 |
1,852 |
$67K |
| D1110 |
Prophylaxis - adult |
1,029 |
1,019 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
658 |
318 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,993 |
2,950 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,531 |
1,510 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,293 |
1,280 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,619 |
1,947 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,161 |
2,116 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
483 |
465 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
28 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
52 |
44 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$204.70 |
| D0603 |
|
4,065 |
4,004 |
$45.62 |
| D9986 |
|
14 |
13 |
$0.00 |