| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,575 |
845 |
$174K |
| D1120 |
Prophylaxis - child |
1,838 |
1,782 |
$88K |
| D1206 |
Topical application of fluoride varnish |
1,982 |
1,924 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,663 |
1,620 |
$49K |
| D8670 |
Periodic orthodontic treatment visit |
186 |
150 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
190 |
69 |
$32K |
| D0272 |
Bitewings - two radiographic images |
766 |
735 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
347 |
342 |
$20K |
| D0274 |
Bitewings - four radiographic images |
440 |
427 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
148 |
114 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
84 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
833 |
728 |
$17K |
| D0330 |
Panoramic radiographic image |
160 |
159 |
$12K |
| D1110 |
Prophylaxis - adult |
122 |
120 |
$8K |
| D1351 |
Sealant - per tooth |
168 |
57 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
54 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
103 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
208 |
$4K |
| D9310 |
|
36 |
32 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
27 |
$846.00 |
| D3120 |
|
21 |
14 |
$840.00 |