| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,783 |
1,013 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
3,149 |
3,146 |
$76K |
| D1120 |
Prophylaxis - child |
2,177 |
2,176 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,134 |
736 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,413 |
3,410 |
$66K |
| D1110 |
Prophylaxis - adult |
1,286 |
1,284 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,968 |
1,966 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
3,612 |
3,579 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,813 |
3,268 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,130 |
1,129 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
185 |
149 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
108 |
40 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
377 |
377 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
410 |
408 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
302 |
287 |
$9K |
| D2332 |
|
87 |
55 |
$6K |
| D1351 |
Sealant - per tooth |
136 |
44 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
26 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
60 |
60 |
$1K |
| D2330 |
|
15 |
12 |
$888.16 |
| D4346 |
|
14 |
14 |
$614.32 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$246.00 |