| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,738 |
637 |
$144K |
| D1120 |
Prophylaxis - child |
3,786 |
3,512 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
3,121 |
2,936 |
$80K |
| D0191 |
|
3,960 |
3,598 |
$55K |
| D1351 |
Sealant - per tooth |
3,129 |
527 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,977 |
3,709 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
909 |
828 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
377 |
177 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
490 |
165 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,732 |
1,634 |
$28K |
| D1110 |
Prophylaxis - adult |
260 |
258 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
458 |
421 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
347 |
276 |
$7K |
| D0330 |
Panoramic radiographic image |
165 |
155 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
561 |
533 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
13 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
153 |
$968.50 |