| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,854 |
986 |
$277K |
| D1351 |
Sealant - per tooth |
6,204 |
1,552 |
$164K |
| D0120 |
Periodic oral evaluation - established patient |
5,592 |
5,488 |
$157K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,415 |
4,927 |
$135K |
| D1120 |
Prophylaxis - child |
3,746 |
3,686 |
$133K |
| D1110 |
Prophylaxis - adult |
1,955 |
1,932 |
$103K |
| D0274 |
Bitewings - four radiographic images |
2,807 |
2,735 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,211 |
451 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,039 |
5,937 |
$86K |
| D0145 |
Oral evaluation for a patient under three years of age |
607 |
604 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
5,487 |
5,361 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
616 |
612 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,454 |
1,364 |
$37K |
| D0272 |
Bitewings - two radiographic images |
786 |
783 |
$18K |
| D9248 |
|
55 |
53 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
129 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
13 |
$4K |
| D0330 |
Panoramic radiographic image |
54 |
53 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$507.06 |
| D0603 |
|
7,110 |
6,981 |
$0.00 |
| D0602 |
|
28 |
28 |
$0.00 |