| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,191 |
635 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,015 |
549 |
$72K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
512 |
178 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,837 |
1,880 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,921 |
1,878 |
$52K |
| D1110 |
Prophylaxis - adult |
1,020 |
989 |
$49K |
| D1120 |
Prophylaxis - child |
1,326 |
1,296 |
$46K |
| D0145 |
Oral evaluation for a patient under three years of age |
272 |
269 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
454 |
436 |
$29K |
| D0274 |
Bitewings - four radiographic images |
854 |
832 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,974 |
1,922 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,204 |
2,135 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
249 |
166 |
$25K |
| D9248 |
|
214 |
205 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
375 |
206 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
241 |
94 |
$18K |
| D1351 |
Sealant - per tooth |
651 |
182 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
392 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
487 |
437 |
$13K |
| D1206 |
Topical application of fluoride varnish |
439 |
427 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
303 |
291 |
$6K |
| D0272 |
Bitewings - two radiographic images |
244 |
239 |
$5K |
| D2950 |
|
28 |
27 |
$1K |
| D2330 |
|
16 |
12 |
$1K |
| D0603 |
|
1,451 |
1,422 |
$0.02 |
| D1999 |
|
38 |
30 |
$0.00 |
| D0602 |
|
876 |
841 |
$0.00 |
| D0601 |
|
330 |
324 |
$0.00 |