| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,141 |
500 |
$106K |
| D1351 |
Sealant - per tooth |
2,821 |
573 |
$75K |
| D1120 |
Prophylaxis - child |
1,192 |
1,184 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,310 |
1,298 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
253 |
252 |
$31K |
| D1110 |
Prophylaxis - adult |
495 |
491 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
370 |
167 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,812 |
1,799 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
484 |
476 |
$16K |
| D0274 |
Bitewings - four radiographic images |
579 |
572 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
595 |
546 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,302 |
430 |
$12K |
| D0330 |
Panoramic radiographic image |
412 |
408 |
$11K |
| D0272 |
Bitewings - two radiographic images |
524 |
518 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
515 |
509 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |
| D0602 |
|
2,424 |
2,391 |
$0.00 |
| D0603 |
|
50 |
49 |
$0.00 |