| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,971 |
999 |
$258K |
| D1120 |
Prophylaxis - child |
4,947 |
4,943 |
$197K |
| D1206 |
Topical application of fluoride varnish |
6,373 |
6,361 |
$143K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,107 |
623 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
3,347 |
3,347 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,602 |
1,601 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
816 |
813 |
$68K |
| D1110 |
Prophylaxis - adult |
1,223 |
1,223 |
$67K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,931 |
1,802 |
$63K |
| D0272 |
Bitewings - two radiographic images |
2,728 |
2,725 |
$60K |
| D1351 |
Sealant - per tooth |
1,026 |
384 |
$43K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,041 |
1,041 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
159 |
84 |
$26K |
| D0274 |
Bitewings - four radiographic images |
779 |
778 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
202 |
145 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
81 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
407 |
401 |
$16K |
| D1354 |
|
703 |
227 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
870 |
858 |
$11K |
| D0240 |
|
207 |
207 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
278 |
$4K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$4K |
| D2330 |
|
34 |
26 |
$4K |
| D9243 |
|
12 |
12 |
$4K |
| D7111 |
|
18 |
13 |
$831.24 |