| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,448 |
629 |
$158K |
| D1206 |
Topical application of fluoride varnish |
3,452 |
3,278 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
3,139 |
2,991 |
$105K |
| D1120 |
Prophylaxis - child |
2,611 |
2,470 |
$94K |
| D1351 |
Sealant - per tooth |
2,519 |
748 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
663 |
384 |
$56K |
| D1110 |
Prophylaxis - adult |
1,072 |
1,030 |
$56K |
| D0330 |
Panoramic radiographic image |
566 |
531 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,907 |
1,806 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
384 |
194 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
180 |
57 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
782 |
732 |
$22K |
| D0274 |
Bitewings - four radiographic images |
823 |
784 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
699 |
649 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
193 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
194 |
$7K |
| D9248 |
|
39 |
39 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
253 |
203 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$1K |
| D1330 |
|
132 |
127 |
$1K |
| D1310 |
|
27 |
27 |
$316.94 |