| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
11,669 |
5,189 |
$763K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,879 |
3,259 |
$465K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,981 |
1,959 |
$225K |
| D0120 |
Periodic oral evaluation - established patient |
10,473 |
9,918 |
$207K |
| D1120 |
Prophylaxis - child |
8,764 |
8,349 |
$201K |
| D1110 |
Prophylaxis - adult |
5,159 |
4,925 |
$200K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,989 |
10,453 |
$194K |
| D0330 |
Panoramic radiographic image |
3,491 |
3,355 |
$157K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,232 |
5,050 |
$156K |
| D0274 |
Bitewings - four radiographic images |
7,081 |
6,730 |
$145K |
| D0210 |
Intraoral - complete series of radiographic images |
2,377 |
1,743 |
$122K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,057 |
499 |
$109K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,470 |
899 |
$89K |
| D0140 |
Limited oral evaluation - problem focused |
2,865 |
2,696 |
$76K |
| D1351 |
Sealant - per tooth |
3,063 |
962 |
$68K |
| D0272 |
Bitewings - two radiographic images |
5,488 |
5,218 |
$58K |
| D2332 |
|
541 |
300 |
$57K |
| D4341 |
|
538 |
182 |
$55K |
| D0240 |
|
5,033 |
1,995 |
$53K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
657 |
547 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
4,034 |
3,758 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,036 |
1,735 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
213 |
104 |
$12K |
| D4342 |
|
149 |
52 |
$10K |
| D2335 |
|
48 |
30 |
$7K |
| D2330 |
|
39 |
27 |
$3K |
| D2140 |
|
60 |
40 |
$2K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$1K |
| D4910 |
|
14 |
12 |
$477.82 |