| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,051 |
915 |
$295K |
| D1120 |
Prophylaxis - child |
5,193 |
4,834 |
$289K |
| D1351 |
Sealant - per tooth |
5,216 |
1,036 |
$206K |
| D0120 |
Periodic oral evaluation - established patient |
4,580 |
4,281 |
$193K |
| D1206 |
Topical application of fluoride varnish |
6,854 |
6,376 |
$172K |
| D0274 |
Bitewings - four radiographic images |
2,540 |
2,348 |
$132K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
904 |
401 |
$102K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,093 |
1,709 |
$97K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
552 |
125 |
$82K |
| D3240 |
|
203 |
62 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
779 |
705 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
559 |
493 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,312 |
1,170 |
$27K |
| D0330 |
Panoramic radiographic image |
309 |
283 |
$26K |
| D1110 |
Prophylaxis - adult |
350 |
322 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
740 |
348 |
$16K |
| D0240 |
|
489 |
358 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
41 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
174 |
163 |
$9K |
| D0272 |
Bitewings - two radiographic images |
44 |
39 |
$2K |
| 9230 |
|
41 |
32 |
$0.00 |
| D1330 |
|
12 |
12 |
$0.00 |
| D1354 |
|
2,943 |
764 |
$0.00 |