| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,297 |
1,927 |
$319K |
| D0120 |
Periodic oral evaluation - established patient |
9,024 |
8,925 |
$251K |
| D1120 |
Prophylaxis - child |
5,921 |
5,840 |
$207K |
| D1351 |
Sealant - per tooth |
7,552 |
1,963 |
$204K |
| D1110 |
Prophylaxis - adult |
3,713 |
3,662 |
$195K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,264 |
1,248 |
$172K |
| D0274 |
Bitewings - four radiographic images |
4,111 |
4,054 |
$120K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,571 |
1,076 |
$118K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,891 |
7,792 |
$111K |
| D0272 |
Bitewings - two radiographic images |
4,551 |
4,487 |
$91K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
777 |
488 |
$76K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,749 |
2,494 |
$71K |
| D0330 |
Panoramic radiographic image |
2,249 |
2,204 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
675 |
675 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
194 |
127 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,456 |
1,429 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
578 |
546 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
958 |
927 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
174 |
170 |
$3K |
| D2394 |
|
17 |
12 |
$2K |
| D9420 |
|
24 |
24 |
$835.13 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
30 |
$287.75 |
| D1999 |
|
627 |
552 |
$0.00 |
| D0603 |
|
11,375 |
11,245 |
$0.00 |
| D0602 |
|
50 |
50 |
$0.00 |