| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,338 |
1,149 |
$305K |
| D1120 |
Prophylaxis - child |
5,346 |
5,253 |
$250K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,467 |
625 |
$250K |
| D1206 |
Topical application of fluoride varnish |
6,570 |
6,456 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
4,954 |
4,865 |
$153K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,226 |
645 |
$148K |
| D9248 |
|
753 |
681 |
$138K |
| D1351 |
Sealant - per tooth |
3,285 |
894 |
$118K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,361 |
1,339 |
$75K |
| D1110 |
Prophylaxis - adult |
1,082 |
1,060 |
$68K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
358 |
291 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
485 |
349 |
$47K |
| D0330 |
Panoramic radiographic image |
1,001 |
976 |
$45K |
| D0272 |
Bitewings - two radiographic images |
2,380 |
2,330 |
$38K |
| D3120 |
|
1,053 |
635 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,255 |
1,124 |
$24K |
| D1330 |
|
3,421 |
3,350 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
441 |
424 |
$21K |
| D0274 |
Bitewings - four radiographic images |
714 |
700 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
272 |
267 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
916 |
885 |
$10K |
| D9310 |
|
90 |
89 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
131 |
$2K |
| D0240 |
|
74 |
74 |
$693.00 |
| D9420 |
|
28 |
28 |
$420.00 |
| D1354 |
|
33 |
12 |
$330.00 |