| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,335 |
641 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
961 |
487 |
$92K |
| D1120 |
Prophylaxis - child |
1,106 |
1,098 |
$39K |
| D1351 |
Sealant - per tooth |
1,354 |
463 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
242 |
242 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,913 |
1,323 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,012 |
1,009 |
$29K |
| D1110 |
Prophylaxis - adult |
529 |
528 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,649 |
1,637 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
606 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,393 |
1,380 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
237 |
237 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
561 |
538 |
$14K |
| D0274 |
Bitewings - four radiographic images |
419 |
417 |
$14K |
| D0272 |
Bitewings - two radiographic images |
441 |
438 |
$10K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$169.02 |
| D9986 |
|
15 |
14 |
$0.00 |
| D0603 |
|
1,934 |
1,927 |
$0.00 |