| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
816 |
349 |
$80K |
| D1351 |
Sealant - per tooth |
2,107 |
422 |
$58K |
| D9248 |
|
441 |
409 |
$53K |
| D0145 |
Oral evaluation for a patient under three years of age |
359 |
342 |
$49K |
| D1120 |
Prophylaxis - child |
1,139 |
1,085 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,116 |
1,064 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,193 |
1,142 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,489 |
412 |
$16K |
| D0274 |
Bitewings - four radiographic images |
299 |
287 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
568 |
542 |
$7K |
| D0272 |
Bitewings - two radiographic images |
291 |
279 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
81 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
86 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
42 |
$1K |
| D0603 |
|
891 |
851 |
$0.00 |
| D0602 |
|
692 |
661 |
$0.00 |