| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,666 |
575 |
$154K |
| D0145 |
Oral evaluation for a patient under three years of age |
871 |
854 |
$111K |
| D1120 |
Prophylaxis - child |
2,626 |
2,550 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,794 |
2,722 |
$73K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
416 |
96 |
$56K |
| D1206 |
Topical application of fluoride varnish |
3,738 |
3,638 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,048 |
2,453 |
$49K |
| D1110 |
Prophylaxis - adult |
793 |
779 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,084 |
1,034 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,354 |
1,294 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
372 |
170 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,912 |
2,792 |
$25K |
| D0330 |
Panoramic radiographic image |
615 |
607 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,035 |
1,002 |
$18K |
| D0274 |
Bitewings - four radiographic images |
300 |
296 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
114 |
55 |
$6K |
| D1351 |
Sealant - per tooth |
170 |
38 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D9420 |
|
38 |
38 |
$1K |
| D0603 |
|
3,297 |
3,224 |
$329.71 |
| D0602 |
|
1,644 |
1,622 |
$228.81 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
12 |
$187.80 |