| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,641 |
1,196 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,947 |
1,248 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,481 |
3,437 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,566 |
3,893 |
$66K |
| D1120 |
Prophylaxis - child |
2,944 |
2,910 |
$63K |
| D1206 |
Topical application of fluoride varnish |
4,029 |
3,978 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
4,160 |
4,103 |
$37K |
| D1110 |
Prophylaxis - adult |
1,132 |
1,117 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
811 |
802 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,131 |
1,021 |
$25K |
| D0274 |
Bitewings - four radiographic images |
920 |
919 |
$19K |
| D1351 |
Sealant - per tooth |
966 |
446 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
211 |
177 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,123 |
1,108 |
$16K |
| D0330 |
Panoramic radiographic image |
439 |
430 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
278 |
206 |
$14K |
| D2332 |
|
141 |
104 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
506 |
478 |
$8K |
| D2331 |
|
34 |
24 |
$2K |
| D0350 |
|
73 |
67 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
68 |
$2K |
| D3120 |
|
60 |
47 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
13 |
$982.00 |