| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,624 |
824 |
$349K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
748 |
347 |
$124K |
| D1351 |
Sealant - per tooth |
3,267 |
786 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,077 |
424 |
$112K |
| D1120 |
Prophylaxis - child |
2,283 |
2,257 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,560 |
1,531 |
$85K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
462 |
158 |
$82K |
| D7140 |
Extraction, erupted tooth or exposed root |
479 |
215 |
$63K |
| D3120 |
|
1,584 |
471 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,319 |
2,288 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,209 |
$38K |
| D0330 |
Panoramic radiographic image |
804 |
786 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
641 |
600 |
$29K |
| D1110 |
Prophylaxis - adult |
424 |
416 |
$27K |
| D0250 |
|
757 |
752 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
875 |
857 |
$17K |
| D1330 |
|
1,840 |
1,815 |
$12K |
| D0272 |
Bitewings - two radiographic images |
747 |
740 |
$12K |
| D0274 |
Bitewings - four radiographic images |
455 |
446 |
$11K |
| D1206 |
Topical application of fluoride varnish |
401 |
401 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
228 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
33 |
$347.68 |