| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
674 |
282 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,174 |
1,146 |
$28K |
| D1351 |
Sealant - per tooth |
1,150 |
203 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
345 |
185 |
$23K |
| D1120 |
Prophylaxis - child |
731 |
708 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
164 |
46 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
140 |
137 |
$17K |
| D0274 |
Bitewings - four radiographic images |
504 |
493 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,356 |
1,311 |
$14K |
| D1110 |
Prophylaxis - adult |
291 |
285 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,089 |
1,055 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,281 |
1,215 |
$12K |
| D0272 |
Bitewings - two radiographic images |
610 |
592 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
323 |
298 |
$7K |
| D9248 |
|
16 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
27 |
$426.63 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$247.24 |
| D0603 |
|
785 |
765 |
$0.00 |
| D0601 |
|
407 |
404 |
$0.00 |
| D0602 |
|
291 |
287 |
$0.00 |