| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,523 |
1,204 |
$221K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,162 |
5,138 |
$111K |
| D9248 |
|
819 |
791 |
$104K |
| D1120 |
Prophylaxis - child |
3,477 |
3,477 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
4,463 |
4,462 |
$91K |
| D0220 |
Intraoral - periapical first radiographic image |
5,633 |
5,598 |
$82K |
| D1110 |
Prophylaxis - adult |
1,483 |
1,483 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,818 |
1,818 |
$53K |
| D1351 |
Sealant - per tooth |
2,200 |
819 |
$52K |
| D0330 |
Panoramic radiographic image |
1,056 |
1,056 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
789 |
559 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,626 |
1,496 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,511 |
2,511 |
$36K |
| D1206 |
Topical application of fluoride varnish |
2,389 |
2,389 |
$36K |
| D0240 |
|
1,771 |
910 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
1,037 |
1,017 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
442 |
274 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
163 |
112 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
130 |
74 |
$14K |
| D0272 |
Bitewings - two radiographic images |
559 |
559 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$6K |
| D2331 |
|
42 |
26 |
$4K |