| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,355 |
1,549 |
$231K |
| D0120 |
Periodic oral evaluation - established patient |
8,206 |
8,005 |
$226K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,602 |
1,572 |
$222K |
| D1351 |
Sealant - per tooth |
7,964 |
1,317 |
$212K |
| D1110 |
Prophylaxis - adult |
3,669 |
3,596 |
$192K |
| D1120 |
Prophylaxis - child |
4,888 |
4,750 |
$170K |
| D0272 |
Bitewings - two radiographic images |
6,140 |
6,000 |
$137K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,560 |
8,346 |
$120K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,758 |
6,724 |
$106K |
| D0220 |
Intraoral - periapical first radiographic image |
7,316 |
7,070 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,041 |
750 |
$78K |
| D0330 |
Panoramic radiographic image |
1,221 |
1,186 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,535 |
2,322 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
203 |
191 |
$7K |
| D2330 |
|
42 |
26 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
50 |
$882.66 |
| D0350 |
|
12 |
12 |
$183.80 |
| D0603 |
|
10,337 |
10,098 |
$0.00 |