| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
758 |
252 |
$75K |
| D1351 |
Sealant - per tooth |
2,242 |
391 |
$60K |
| D0145 |
Oral evaluation for a patient under three years of age |
320 |
311 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
287 |
90 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,712 |
757 |
$28K |
| D1120 |
Prophylaxis - child |
582 |
564 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
535 |
$19K |
| D9248 |
|
152 |
141 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
61 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
849 |
799 |
$10K |
| D1206 |
Topical application of fluoride varnish |
699 |
681 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
178 |
170 |
$5K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$4K |
| D0274 |
Bitewings - four radiographic images |
112 |
112 |
$4K |
| D0272 |
Bitewings - two radiographic images |
167 |
160 |
$4K |
| D1330 |
|
316 |
314 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
122 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
164 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$325.75 |
| D0603 |
|
1,009 |
984 |
$0.00 |