| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,077 |
1,126 |
$387K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,471 |
627 |
$185K |
| D0145 |
Oral evaluation for a patient under three years of age |
936 |
904 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
4,153 |
4,083 |
$112K |
| D1120 |
Prophylaxis - child |
3,318 |
3,240 |
$111K |
| D1110 |
Prophylaxis - adult |
1,398 |
1,377 |
$71K |
| D0274 |
Bitewings - four radiographic images |
2,058 |
2,029 |
$67K |
| D1351 |
Sealant - per tooth |
2,825 |
635 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,784 |
4,685 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
4,125 |
4,050 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,105 |
3,909 |
$45K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
218 |
43 |
$31K |
| D7240 |
Removal of impacted tooth - completely bony |
109 |
32 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,059 |
1,045 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
737 |
694 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
592 |
573 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
239 |
229 |
$15K |
| D9248 |
|
64 |
63 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
46 |
$6K |
| D0350 |
|
46 |
46 |
$827.10 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$262.92 |
| D0603 |
|
6,051 |
5,912 |
$0.00 |