| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,972 |
3,279 |
$428K |
| D0120 |
Periodic oral evaluation - established patient |
10,830 |
10,723 |
$265K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,305 |
11,176 |
$234K |
| D1110 |
Prophylaxis - adult |
5,003 |
4,939 |
$217K |
| D1120 |
Prophylaxis - child |
6,421 |
6,363 |
$216K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,479 |
2,151 |
$207K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,334 |
856 |
$111K |
| D0274 |
Bitewings - four radiographic images |
4,062 |
4,011 |
$108K |
| D0220 |
Intraoral - periapical first radiographic image |
7,542 |
7,404 |
$94K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,856 |
5,957 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
397 |
139 |
$45K |
| D0272 |
Bitewings - two radiographic images |
2,447 |
2,421 |
$43K |
| D1354 |
|
4,562 |
1,587 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,289 |
1,261 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
860 |
844 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
134 |
123 |
$4K |
| D2332 |
|
40 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
101 |
27 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
74 |
74 |
$2K |
| D4346 |
|
12 |
12 |
$526.56 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$383.35 |
| D1999 |
|
428 |
396 |
$0.00 |