| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,312 |
2,284 |
$446K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,764 |
1,729 |
$350K |
| D1120 |
Prophylaxis - child |
8,295 |
8,293 |
$291K |
| D0120 |
Periodic oral evaluation - established patient |
9,985 |
9,985 |
$237K |
| D1110 |
Prophylaxis - adult |
4,178 |
4,178 |
$210K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,528 |
625 |
$205K |
| D1206 |
Topical application of fluoride varnish |
12,095 |
12,093 |
$200K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,114 |
4,801 |
$166K |
| D0272 |
Bitewings - two radiographic images |
6,083 |
6,083 |
$116K |
| D0274 |
Bitewings - four radiographic images |
3,191 |
3,191 |
$89K |
| D9920 |
|
1,463 |
1,424 |
$82K |
| D1351 |
Sealant - per tooth |
2,543 |
841 |
$76K |
| D2330 |
|
650 |
176 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
5,400 |
5,379 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,401 |
1,399 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,336 |
4,133 |
$48K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
289 |
210 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
665 |
665 |
$36K |
| D0145 |
Oral evaluation for a patient under three years of age |
489 |
489 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
279 |
168 |
$28K |
| D0330 |
Panoramic radiographic image |
572 |
572 |
$26K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
148 |
38 |
$14K |
| D9222 |
|
38 |
38 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
174 |
173 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
274 |
274 |
$4K |
| D1354 |
|
297 |
82 |
$4K |
| D2332 |
|
33 |
18 |
$4K |
| D7111 |
|
38 |
27 |
$2K |