| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,535 |
2,358 |
$267K |
| D0120 |
Periodic oral evaluation - established patient |
10,097 |
9,795 |
$225K |
| D1120 |
Prophylaxis - child |
8,383 |
8,062 |
$179K |
| D1206 |
Topical application of fluoride varnish |
10,872 |
10,470 |
$165K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,311 |
480 |
$149K |
| D1351 |
Sealant - per tooth |
4,855 |
1,356 |
$94K |
| D1110 |
Prophylaxis - adult |
2,286 |
2,221 |
$74K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,346 |
739 |
$70K |
| D0272 |
Bitewings - two radiographic images |
6,703 |
6,451 |
$64K |
| D9999 |
Unspecified adjunctive procedure, by report |
2,395 |
2,287 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,829 |
2,553 |
$52K |
| D0330 |
Panoramic radiographic image |
1,389 |
1,338 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
940 |
614 |
$45K |
| D9248 |
|
832 |
754 |
$38K |
| D1999 |
|
3,119 |
2,896 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
575 |
403 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
843 |
753 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,411 |
1,368 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,524 |
1,421 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
465 |
432 |
$8K |
| D9630 |
|
173 |
161 |
$7K |
| D9920 |
|
14 |
13 |
$380.46 |
| D0240 |
|
49 |
31 |
$356.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
95 |
$293.88 |