| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,236 |
1,326 |
$271K |
| D1120 |
Prophylaxis - child |
5,859 |
5,859 |
$245K |
| D0120 |
Periodic oral evaluation - established patient |
5,255 |
5,255 |
$177K |
| D1206 |
Topical application of fluoride varnish |
5,836 |
5,836 |
$164K |
| D0272 |
Bitewings - two radiographic images |
2,281 |
2,279 |
$55K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
258 |
132 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
472 |
380 |
$43K |
| D1351 |
Sealant - per tooth |
1,310 |
511 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
1,180 |
1,175 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
271 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
717 |
304 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
26 |
$4K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$4K |
| D0240 |
|
192 |
140 |
$3K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$3K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$2K |
| D9310 |
|
16 |
16 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,823 |
1,744 |
$0.00 |