| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,352 |
1,319 |
$174K |
| D1120 |
Prophylaxis - child |
3,968 |
3,886 |
$128K |
| D1206 |
Topical application of fluoride varnish |
4,996 |
4,892 |
$105K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
922 |
214 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,751 |
3,671 |
$90K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,895 |
2,497 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
5,194 |
4,968 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,889 |
4,636 |
$61K |
| D1110 |
Prophylaxis - adult |
1,276 |
1,249 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
716 |
494 |
$45K |
| D1351 |
Sealant - per tooth |
1,423 |
562 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
709 |
323 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,363 |
1,319 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,892 |
1,845 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,115 |
1,103 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
169 |
128 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
428 |
410 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
242 |
$9K |
| D8670 |
Periodic orthodontic treatment visit |
116 |
74 |
$4K |
| D0330 |
Panoramic radiographic image |
131 |
131 |
$4K |
| D2332 |
|
21 |
14 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$1K |
| D8660 |
|
39 |
33 |
$156.48 |