| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
11,339 |
7,052 |
$1.22M |
| D0120 |
Periodic oral evaluation - established patient |
42,688 |
42,030 |
$1.10M |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
10,159 |
6,408 |
$826K |
| D1110 |
Prophylaxis - adult |
18,747 |
18,459 |
$719K |
| D1120 |
Prophylaxis - child |
26,341 |
25,915 |
$718K |
| D1206 |
Topical application of fluoride varnish |
39,524 |
38,913 |
$642K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,900 |
1,488 |
$549K |
| D1351 |
Sealant - per tooth |
17,696 |
4,793 |
$505K |
| D7140 |
Extraction, erupted tooth or exposed root |
7,681 |
4,155 |
$488K |
| D0220 |
Intraoral - periapical first radiographic image |
28,264 |
27,485 |
$425K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,871 |
22,174 |
$312K |
| D0274 |
Bitewings - four radiographic images |
9,412 |
9,249 |
$300K |
| D0330 |
Panoramic radiographic image |
5,186 |
5,106 |
$290K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,699 |
6,255 |
$289K |
| D0272 |
Bitewings - two radiographic images |
11,907 |
11,689 |
$221K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,586 |
1,229 |
$209K |
| D0140 |
Limited oral evaluation - problem focused |
4,420 |
4,248 |
$158K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,046 |
2,962 |
$127K |
| D9420 |
|
818 |
724 |
$88K |
| D2332 |
|
750 |
500 |
$73K |
| D2331 |
|
747 |
508 |
$62K |
| D5110 |
|
102 |
101 |
$58K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
537 |
408 |
$50K |
| D2330 |
|
716 |
512 |
$47K |
| D5120 |
|
56 |
56 |
$31K |
| D2335 |
|
114 |
80 |
$13K |
| D4355 |
|
196 |
191 |
$13K |
| D2140 |
|
152 |
128 |
$12K |
| D2160 |
|
42 |
38 |
$5K |
| D1510 |
|
13 |
12 |
$3K |
| D1354 |
|
21 |
12 |
$190.53 |