| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,619 |
1,840 |
$373K |
| D0120 |
Periodic oral evaluation - established patient |
9,021 |
8,460 |
$227K |
| D1120 |
Prophylaxis - child |
7,590 |
7,134 |
$201K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
768 |
322 |
$108K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,330 |
2,181 |
$103K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
795 |
570 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,767 |
5,405 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,149 |
759 |
$90K |
| D1110 |
Prophylaxis - adult |
2,077 |
1,939 |
$76K |
| D1351 |
Sealant - per tooth |
2,525 |
833 |
$69K |
| D0272 |
Bitewings - two radiographic images |
3,193 |
3,001 |
$57K |
| D1206 |
Topical application of fluoride varnish |
3,565 |
3,359 |
$56K |
| D0330 |
Panoramic radiographic image |
941 |
869 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
612 |
355 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,020 |
1,887 |
$29K |
| D0274 |
Bitewings - four radiographic images |
934 |
867 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
621 |
578 |
$27K |
| D9420 |
|
158 |
150 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,579 |
1,336 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
113 |
68 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
145 |
$5K |
| D1354 |
|
65 |
32 |
$522.50 |