| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,573 |
624 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
3,578 |
3,451 |
$95K |
| D0145 |
Oral evaluation for a patient under three years of age |
638 |
625 |
$87K |
| D1120 |
Prophylaxis - child |
2,330 |
2,255 |
$79K |
| D1351 |
Sealant - per tooth |
2,980 |
690 |
$74K |
| D1110 |
Prophylaxis - adult |
1,481 |
1,423 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,049 |
1,956 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,598 |
2,967 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,717 |
3,589 |
$51K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
468 |
232 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
510 |
302 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,159 |
3,040 |
$33K |
| D0330 |
Panoramic radiographic image |
896 |
814 |
$20K |
| D0272 |
Bitewings - two radiographic images |
951 |
912 |
$19K |
| D0350 |
|
1,254 |
1,204 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
372 |
347 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
12 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
275 |
257 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
124 |
113 |
$2K |
| D9248 |
|
20 |
18 |
$853.16 |
| D0160 |
|
47 |
45 |
$581.56 |
| D1206 |
Topical application of fluoride varnish |
35 |
34 |
$498.33 |
| D1330 |
|
49 |
47 |
$416.50 |
| D0601 |
|
2,312 |
2,287 |
$0.02 |
| D0603 |
|
2,076 |
1,984 |
$0.00 |
| D0602 |
|
282 |
277 |
$0.00 |