| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,643 |
2,961 |
$583K |
| D1351 |
Sealant - per tooth |
20,996 |
5,435 |
$566K |
| D1120 |
Prophylaxis - child |
15,634 |
15,098 |
$414K |
| D0120 |
Periodic oral evaluation - established patient |
11,722 |
11,479 |
$298K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,557 |
6,208 |
$256K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,584 |
14,056 |
$234K |
| D0330 |
Panoramic radiographic image |
3,752 |
3,570 |
$204K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,913 |
10,683 |
$194K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,963 |
3,813 |
$166K |
| D0220 |
Intraoral - periapical first radiographic image |
11,212 |
10,753 |
$163K |
| D0272 |
Bitewings - two radiographic images |
8,640 |
8,345 |
$151K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,539 |
1,148 |
$119K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
812 |
603 |
$101K |
| D1110 |
Prophylaxis - adult |
2,046 |
1,992 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,855 |
2,800 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,449 |
1,407 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
204 |
105 |
$31K |
| D4355 |
|
145 |
143 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
239 |
230 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
57 |
$5K |
| D7250 |
|
29 |
12 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
47 |
$3K |
| D2335 |
|
25 |
13 |
$3K |
| D2331 |
|
27 |
18 |
$2K |
| D2330 |
|
23 |
14 |
$2K |