| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,398 |
948 |
$235K |
| D1351 |
Sealant - per tooth |
5,300 |
1,086 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
4,278 |
4,181 |
$118K |
| D1110 |
Prophylaxis - adult |
2,001 |
1,952 |
$102K |
| D1120 |
Prophylaxis - child |
2,634 |
2,576 |
$92K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,768 |
4,051 |
$84K |
| D0145 |
Oral evaluation for a patient under three years of age |
478 |
473 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,689 |
4,586 |
$66K |
| D0220 |
Intraoral - periapical first radiographic image |
4,566 |
4,360 |
$54K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
242 |
84 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,295 |
1,267 |
$29K |
| D0274 |
Bitewings - four radiographic images |
864 |
850 |
$29K |
| D9248 |
|
225 |
216 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
316 |
96 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
951 |
893 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
45 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
92 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
176 |
$3K |
| D1330 |
|
225 |
219 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$887.22 |
| D0602 |
|
4,600 |
4,529 |
$0.00 |
| D0603 |
|
703 |
691 |
$0.00 |