| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,708 |
954 |
$251K |
| D1351 |
Sealant - per tooth |
7,068 |
1,269 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
5,091 |
4,883 |
$135K |
| D1120 |
Prophylaxis - child |
3,692 |
3,559 |
$126K |
| D1110 |
Prophylaxis - adult |
2,377 |
2,247 |
$112K |
| D0145 |
Oral evaluation for a patient under three years of age |
824 |
807 |
$111K |
| D0274 |
Bitewings - four radiographic images |
3,014 |
2,900 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,749 |
5,516 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
5,425 |
5,149 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,052 |
4,812 |
$52K |
| D1352 |
|
1,908 |
412 |
$49K |
| D0272 |
Bitewings - two radiographic images |
1,978 |
1,927 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
638 |
222 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
672 |
634 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,063 |
994 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
666 |
561 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
78 |
39 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
36 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
146 |
$3K |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$412.64 |
| D0602 |
|
655 |
628 |
$0.00 |
| D0603 |
|
6,018 |
5,805 |
$0.00 |