| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
492 |
231 |
$76K |
| D1120 |
Prophylaxis - child |
1,225 |
1,218 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,277 |
1,268 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
727 |
727 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
439 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
39 |
$15K |
| D0272 |
Bitewings - two radiographic images |
451 |
447 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
228 |
213 |
$13K |
| D9248 |
|
90 |
81 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
16 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
561 |
542 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
694 |
417 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
24 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
89 |
$5K |
| D1110 |
Prophylaxis - adult |
80 |
80 |
$4K |
| D0603 |
|
643 |
642 |
$4K |
| D1351 |
Sealant - per tooth |
129 |
39 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
98 |
98 |
$3K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$2K |
| D0240 |
|
62 |
37 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$870.00 |
| D0602 |
|
87 |
87 |
$518.65 |
| D1330 |
|
735 |
735 |
$0.07 |
| D1310 |
|
735 |
735 |
$0.04 |