| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,846 |
642 |
$280K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,454 |
355 |
$114K |
| D0145 |
Oral evaluation for a patient under three years of age |
412 |
407 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,187 |
1,167 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,956 |
843 |
$32K |
| D1351 |
Sealant - per tooth |
1,103 |
244 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
344 |
342 |
$24K |
| D1120 |
Prophylaxis - child |
641 |
634 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
678 |
657 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
904 |
896 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
967 |
913 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
12 |
$9K |
| D1110 |
Prophylaxis - adult |
147 |
147 |
$8K |
| D0274 |
Bitewings - four radiographic images |
219 |
214 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
167 |
167 |
$5K |
| D1330 |
|
320 |
314 |
$4K |
| D0272 |
Bitewings - two radiographic images |
93 |
93 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
78 |
$1K |
| D0350 |
|
46 |
46 |
$477.88 |
| D0603 |
|
2,003 |
1,985 |
$0.00 |