| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,195 |
3,767 |
$624K |
| D0274 |
Bitewings - four radiographic images |
12,969 |
12,969 |
$581K |
| D0120 |
Periodic oral evaluation - established patient |
13,821 |
13,821 |
$520K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,289 |
2,119 |
$357K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,587 |
2,387 |
$349K |
| D1120 |
Prophylaxis - child |
10,502 |
10,502 |
$318K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,325 |
14,325 |
$261K |
| D1110 |
Prophylaxis - adult |
4,166 |
4,166 |
$126K |
| D1351 |
Sealant - per tooth |
1,050 |
804 |
$123K |
| D9110 |
|
807 |
793 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
315 |
277 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
257 |
242 |
$41K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
292 |
277 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
621 |
621 |
$18K |
| D0330 |
Panoramic radiographic image |
149 |
149 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
394 |
$7K |
| D1206 |
Topical application of fluoride varnish |
182 |
182 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
119 |
110 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
47 |
$2K |
| D9995 |
|
44 |
44 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
16 |
$373.75 |