| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,484 |
469 |
$141K |
| D0145 |
Oral evaluation for a patient under three years of age |
885 |
830 |
$111K |
| D1120 |
Prophylaxis - child |
1,439 |
1,403 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
355 |
65 |
$45K |
| D1351 |
Sealant - per tooth |
1,520 |
359 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,049 |
1,005 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,751 |
1,402 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
799 |
768 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,724 |
1,687 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,631 |
1,575 |
$17K |
| D1110 |
Prophylaxis - adult |
289 |
279 |
$14K |
| D0272 |
Bitewings - two radiographic images |
832 |
819 |
$13K |
| D0274 |
Bitewings - four radiographic images |
420 |
405 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
154 |
$11K |
| D7240 |
Removal of impacted tooth - completely bony |
36 |
12 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
308 |
296 |
$7K |
| D0330 |
Panoramic radiographic image |
335 |
334 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
25 |
$4K |
| D9248 |
|
14 |
13 |
$1K |
| D9222 |
|
13 |
13 |
$751.74 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
23 |
13 |
$745.96 |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$426.30 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$356.82 |
| D0160 |
|
12 |
12 |
$179.40 |
| D0603 |
|
2,836 |
2,756 |
$0.02 |