| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,264 |
608 |
$163K |
| D1120 |
Prophylaxis - child |
2,964 |
2,912 |
$132K |
| D1351 |
Sealant - per tooth |
3,373 |
839 |
$119K |
| D1206 |
Topical application of fluoride varnish |
4,104 |
4,041 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
826 |
432 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,729 |
2,685 |
$82K |
| D1110 |
Prophylaxis - adult |
1,059 |
1,048 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
924 |
912 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
621 |
603 |
$29K |
| D9248 |
|
126 |
115 |
$24K |
| D0330 |
Panoramic radiographic image |
531 |
521 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,207 |
1,184 |
$19K |
| D1330 |
|
1,756 |
1,731 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
597 |
547 |
$11K |
| D0274 |
Bitewings - four radiographic images |
381 |
374 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
836 |
817 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
122 |
121 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
15 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |
| D3120 |
|
61 |
43 |
$2K |
| D0250 |
|
75 |
75 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
114 |
$742.80 |