| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
702 |
491 |
$84K |
| D1206 |
Topical application of fluoride varnish |
2,203 |
2,121 |
$59K |
| D1120 |
Prophylaxis - child |
1,559 |
1,495 |
$55K |
| D1110 |
Prophylaxis - adult |
698 |
673 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,442 |
1,387 |
$40K |
| D0330 |
Panoramic radiographic image |
442 |
432 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
361 |
258 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,140 |
701 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
144 |
115 |
$25K |
| D0272 |
Bitewings - two radiographic images |
995 |
958 |
$25K |
| D1351 |
Sealant - per tooth |
755 |
268 |
$21K |
| D0274 |
Bitewings - four radiographic images |
556 |
548 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
952 |
890 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
161 |
88 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
268 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
380 |
254 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
129 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
45 |
28 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
42 |
$536.00 |
| D0240 |
|
39 |
25 |
$239.00 |