| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,346 |
909 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
4,744 |
4,624 |
$122K |
| D1120 |
Prophylaxis - child |
4,046 |
3,913 |
$109K |
| D1351 |
Sealant - per tooth |
3,742 |
924 |
$102K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,197 |
5,030 |
$85K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
491 |
262 |
$66K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,472 |
1,288 |
$62K |
| D1110 |
Prophylaxis - adult |
1,523 |
1,479 |
$56K |
| D0330 |
Panoramic radiographic image |
716 |
673 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
805 |
747 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
432 |
325 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,866 |
1,799 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,325 |
2,079 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
389 |
275 |
$24K |
| D0274 |
Bitewings - four radiographic images |
739 |
723 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
613 |
570 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
102 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,060 |
718 |
$12K |
| D2330 |
|
94 |
42 |
$6K |
| D2332 |
|
47 |
33 |
$4K |
| D9420 |
|
28 |
27 |
$3K |
| D2335 |
|
16 |
13 |
$2K |
| D0170 |
|
41 |
41 |
$1K |
| D0240 |
|
50 |
47 |
$802.08 |
| D1354 |
|
144 |
49 |
$731.50 |