| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,205 |
1,261 |
$286K |
| D1120 |
Prophylaxis - child |
4,790 |
4,724 |
$223K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,017 |
447 |
$171K |
| D1206 |
Topical application of fluoride varnish |
5,929 |
5,849 |
$150K |
| D1351 |
Sealant - per tooth |
4,082 |
1,301 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
3,433 |
3,403 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,650 |
1,604 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
671 |
356 |
$79K |
| D9248 |
|
388 |
355 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
600 |
390 |
$60K |
| D3120 |
|
1,553 |
748 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,336 |
2,064 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
195 |
$40K |
| D0330 |
Panoramic radiographic image |
713 |
698 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,736 |
1,698 |
$27K |
| D1330 |
|
3,038 |
2,985 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,216 |
1,163 |
$13K |
| D2940 |
|
271 |
81 |
$12K |
| D1110 |
Prophylaxis - adult |
173 |
172 |
$11K |
| D9310 |
|
219 |
207 |
$10K |
| D0274 |
Bitewings - four radiographic images |
266 |
265 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
106 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
108 |
$1K |
| D0240 |
|
88 |
82 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$322.00 |