| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,542 |
845 |
$376K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,069 |
1,086 |
$364K |
| D1120 |
Prophylaxis - child |
2,787 |
2,743 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
871 |
434 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,351 |
2,313 |
$68K |
| D1351 |
Sealant - per tooth |
2,013 |
626 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
548 |
277 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,101 |
2,081 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,951 |
1,699 |
$35K |
| D2335 |
|
237 |
99 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,988 |
1,956 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
166 |
41 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,002 |
974 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
325 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
361 |
352 |
$16K |
| D2330 |
|
132 |
69 |
$11K |
| D1330 |
|
1,413 |
1,383 |
$8K |
| D0274 |
Bitewings - four radiographic images |
265 |
264 |
$6K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$5K |
| D3120 |
|
100 |
41 |
$4K |
| D2332 |
|
20 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0240 |
|
27 |
27 |
$342.00 |