| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,294 |
584 |
$105K |
| D0145 |
Oral evaluation for a patient under three years of age |
748 |
735 |
$92K |
| D1351 |
Sealant - per tooth |
3,813 |
848 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,976 |
2,884 |
$70K |
| D1120 |
Prophylaxis - child |
2,186 |
2,144 |
$64K |
| D1110 |
Prophylaxis - adult |
1,154 |
1,106 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,333 |
2,947 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,674 |
1,600 |
$45K |
| D1206 |
Topical application of fluoride varnish |
3,164 |
3,100 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,277 |
3,161 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,205 |
1,072 |
$26K |
| D0272 |
Bitewings - two radiographic images |
714 |
709 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
476 |
445 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
102 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
13 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
37 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$268.49 |
| D7111 |
|
24 |
12 |
$205.11 |
| D0603 |
|
1,193 |
1,176 |
$0.00 |
| D0602 |
|
3,057 |
3,012 |
$0.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |