| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
961 |
480 |
$119K |
| D1120 |
Prophylaxis - child |
2,224 |
2,202 |
$98K |
| D1206 |
Topical application of fluoride varnish |
3,428 |
3,393 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,861 |
2,827 |
$85K |
| D1110 |
Prophylaxis - adult |
1,285 |
1,268 |
$79K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
488 |
193 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
925 |
914 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,747 |
1,720 |
$46K |
| D0330 |
Panoramic radiographic image |
922 |
904 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,899 |
3,816 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
462 |
257 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,668 |
3,599 |
$29K |
| D1351 |
Sealant - per tooth |
782 |
165 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
32 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,149 |
1,140 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
649 |
618 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
258 |
246 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
485 |
475 |
$11K |
| D1330 |
|
1,585 |
1,566 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
38 |
$10K |
| D7230 |
|
25 |
15 |
$6K |
| D9310 |
|
12 |
12 |
$1K |
| D0240 |
|
15 |
15 |
$171.00 |