| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,529 |
1,139 |
$53K |
| D1120 |
Prophylaxis - child |
4,013 |
3,967 |
$42K |
| D1206 |
Topical application of fluoride varnish |
5,378 |
5,322 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
3,444 |
3,412 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,027 |
2,004 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
5,650 |
5,536 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,387 |
4,692 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
378 |
84 |
$18K |
| D1110 |
Prophylaxis - adult |
1,400 |
1,385 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,614 |
1,595 |
$12K |
| D0272 |
Bitewings - two radiographic images |
2,179 |
2,153 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
398 |
226 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
638 |
402 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
811 |
788 |
$8K |
| D1351 |
Sealant - per tooth |
676 |
226 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
692 |
637 |
$5K |
| D0330 |
Panoramic radiographic image |
217 |
213 |
$2K |
| D2332 |
|
41 |
24 |
$1K |
| D2394 |
|
19 |
12 |
$578.50 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$350.35 |
| D9430 |
|
15 |
15 |
$74.70 |
| D0603 |
|
848 |
752 |
$0.00 |
| D0602 |
|
1,413 |
1,226 |
$0.00 |
| D0601 |
|
157 |
151 |
$0.00 |