| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,643 |
730 |
$214K |
| D0145 |
Oral evaluation for a patient under three years of age |
933 |
928 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
3,286 |
3,259 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,147 |
3,291 |
$80K |
| D1120 |
Prophylaxis - child |
2,469 |
2,449 |
$71K |
| D1351 |
Sealant - per tooth |
2,973 |
516 |
$66K |
| D1110 |
Prophylaxis - adult |
1,282 |
1,266 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
4,235 |
4,162 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,254 |
3,224 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
427 |
200 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
626 |
617 |
$19K |
| D0272 |
Bitewings - two radiographic images |
988 |
976 |
$19K |
| D0330 |
Panoramic radiographic image |
582 |
572 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
63 |
25 |
$9K |
| D1206 |
Topical application of fluoride varnish |
423 |
422 |
$6K |
| D0274 |
Bitewings - four radiographic images |
212 |
210 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
38 |
36 |
$840.47 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$144.93 |
| D0603 |
|
5,330 |
5,288 |
$103.76 |