| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,201 |
673 |
$130K |
| D1120 |
Prophylaxis - child |
3,506 |
3,348 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,541 |
1,354 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,328 |
2,261 |
$60K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
431 |
114 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,255 |
1,157 |
$53K |
| D1351 |
Sealant - per tooth |
1,333 |
371 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,214 |
2,091 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,724 |
872 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,794 |
1,734 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
455 |
196 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
189 |
119 |
$25K |
| D0330 |
Panoramic radiographic image |
441 |
408 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,390 |
1,284 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
229 |
148 |
$19K |
| D1110 |
Prophylaxis - adult |
484 |
460 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
407 |
379 |
$15K |
| D0272 |
Bitewings - two radiographic images |
626 |
595 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
315 |
292 |
$11K |
| D0274 |
Bitewings - four radiographic images |
220 |
207 |
$6K |
| D9420 |
|
48 |
42 |
$5K |
| D2332 |
|
21 |
12 |
$2K |
| D2950 |
|
14 |
13 |
$1K |