| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,307 |
2,494 |
$447K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,354 |
1,822 |
$263K |
| D0120 |
Periodic oral evaluation - established patient |
10,403 |
10,403 |
$243K |
| D1120 |
Prophylaxis - child |
6,602 |
6,601 |
$231K |
| D1110 |
Prophylaxis - adult |
4,279 |
4,279 |
$215K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,599 |
6,261 |
$213K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,680 |
11,679 |
$192K |
| D9248 |
|
2,756 |
2,616 |
$189K |
| D0272 |
Bitewings - two radiographic images |
7,942 |
7,941 |
$150K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,007 |
609 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
673 |
445 |
$84K |
| D0330 |
Panoramic radiographic image |
1,448 |
1,447 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
997 |
996 |
$41K |
| D1351 |
Sealant - per tooth |
1,217 |
431 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,086 |
1,086 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
177 |
126 |
$25K |
| D0145 |
Oral evaluation for a patient under three years of age |
347 |
347 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
293 |
288 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
602 |
594 |
$8K |
| D0240 |
|
319 |
210 |
$6K |
| D2330 |
|
82 |
57 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
26 |
$423.53 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$421.20 |