| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,450 |
1,579 |
$438K |
| D1120 |
Prophylaxis - child |
8,022 |
8,022 |
$365K |
| D1351 |
Sealant - per tooth |
3,968 |
1,547 |
$255K |
| D1206 |
Topical application of fluoride varnish |
7,310 |
7,310 |
$235K |
| D0120 |
Periodic oral evaluation - established patient |
6,933 |
6,933 |
$200K |
| D1110 |
Prophylaxis - adult |
2,489 |
2,489 |
$142K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,135 |
3,135 |
$99K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
394 |
258 |
$70K |
| D0272 |
Bitewings - two radiographic images |
3,138 |
3,138 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
763 |
540 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,854 |
2,854 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,411 |
1,411 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
234 |
174 |
$38K |
| D0330 |
Panoramic radiographic image |
910 |
910 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,051 |
1,031 |
$23K |
| D0240 |
|
800 |
719 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,476 |
1,474 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
507 |
507 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
752 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
525 |
515 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
38 |
$3K |
| D9420 |
|
30 |
30 |
$3K |
| D1354 |
|
105 |
27 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$100.30 |