| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
808 |
808 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
586 |
303 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
449 |
257 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
441 |
441 |
$21K |
| D1120 |
Prophylaxis - child |
463 |
461 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
583 |
582 |
$9K |
| D0350 |
|
932 |
356 |
$8K |
| D1351 |
Sealant - per tooth |
195 |
64 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,749 |
310 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
161 |
104 |
$6K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$6K |
| D1310 |
|
143 |
143 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
263 |
263 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$1K |
| D2332 |
|
14 |
12 |
$1K |
| D0603 |
|
16 |
16 |
$210.00 |
| D0601 |
|
12 |
12 |
$180.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$144.00 |