| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
12,420 |
12,225 |
$305K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,430 |
1,448 |
$280K |
| D1120 |
Prophylaxis - child |
6,603 |
6,504 |
$275K |
| D0120 |
Periodic oral evaluation - established patient |
6,592 |
6,496 |
$187K |
| D1351 |
Sealant - per tooth |
4,625 |
1,484 |
$151K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,649 |
1,133 |
$148K |
| D7140 |
Extraction, erupted tooth or exposed root |
884 |
528 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
560 |
374 |
$85K |
| D1110 |
Prophylaxis - adult |
1,150 |
1,128 |
$64K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,964 |
2,771 |
$53K |
| D0272 |
Bitewings - two radiographic images |
3,212 |
3,166 |
$47K |
| D0330 |
Panoramic radiographic image |
1,046 |
1,028 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
718 |
700 |
$36K |
| D1330 |
|
4,176 |
4,113 |
$25K |
| D0274 |
Bitewings - four radiographic images |
652 |
646 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,498 |
1,459 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
65 |
$11K |
| D3120 |
|
177 |
120 |
$6K |
| D9248 |
|
29 |
27 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
73 |
$668.04 |
| D9310 |
|
13 |
13 |
$624.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$561.60 |