| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,725 |
1,121 |
$263K |
| D1351 |
Sealant - per tooth |
5,944 |
1,445 |
$154K |
| D1120 |
Prophylaxis - child |
2,647 |
2,612 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,221 |
585 |
$91K |
| D0145 |
Oral evaluation for a patient under three years of age |
574 |
571 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,778 |
2,750 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,703 |
3,641 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,568 |
1,539 |
$42K |
| D1110 |
Prophylaxis - adult |
761 |
746 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,520 |
1,499 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
598 |
575 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,757 |
565 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
32 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
802 |
766 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
50 |
$3K |
| D0330 |
Panoramic radiographic image |
90 |
82 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
27 |
$731.97 |
| D0603 |
|
4,772 |
4,720 |
$18.10 |