| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,706 |
2,512 |
$381K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,332 |
2,097 |
$256K |
| D0120 |
Periodic oral evaluation - established patient |
8,913 |
8,572 |
$224K |
| D1120 |
Prophylaxis - child |
7,494 |
7,288 |
$200K |
| D1110 |
Prophylaxis - adult |
3,139 |
3,054 |
$119K |
| D0220 |
Intraoral - periapical first radiographic image |
7,256 |
6,901 |
$106K |
| D1206 |
Topical application of fluoride varnish |
6,382 |
6,120 |
$101K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,180 |
5,889 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,810 |
1,756 |
$79K |
| D0274 |
Bitewings - four radiographic images |
2,232 |
2,120 |
$69K |
| D0272 |
Bitewings - two radiographic images |
3,070 |
2,979 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,331 |
3,229 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
380 |
282 |
$46K |
| D1351 |
Sealant - per tooth |
1,417 |
376 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
127 |
92 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
208 |
144 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
337 |
317 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
254 |
238 |
$12K |
| D4355 |
|
30 |
29 |
$2K |
| D9440 |
|
27 |
23 |
$2K |
| D9996 |
|
42 |
33 |
$701.50 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$532.14 |
| D0170 |
|
14 |
12 |
$398.15 |