| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,659 |
1,910 |
$570K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,995 |
3,966 |
$136K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,011 |
4,043 |
$126K |
| D1120 |
Prophylaxis - child |
2,720 |
2,696 |
$97K |
| D1351 |
Sealant - per tooth |
3,320 |
1,022 |
$87K |
| D1110 |
Prophylaxis - adult |
1,394 |
1,382 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,130 |
4,096 |
$60K |
| D0274 |
Bitewings - four radiographic images |
2,048 |
2,032 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
4,101 |
4,040 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
402 |
251 |
$31K |
| D0145 |
Oral evaluation for a patient under three years of age |
161 |
158 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
660 |
643 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
222 |
222 |
$16K |
| D0272 |
Bitewings - two radiographic images |
624 |
619 |
$14K |
| D2335 |
|
48 |
36 |
$8K |
| D0330 |
Panoramic radiographic image |
551 |
550 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
28 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
145 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
12 |
$4K |
| D7111 |
|
37 |
25 |
$330.68 |
| D0603 |
|
4,521 |
4,450 |
$0.00 |
| D0602 |
|
20 |
19 |
$0.00 |