| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,078 |
2,888 |
$659K |
| D1120 |
Prophylaxis - child |
18,851 |
18,658 |
$636K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,081 |
1,422 |
$500K |
| D0120 |
Periodic oral evaluation - established patient |
19,310 |
19,143 |
$460K |
| D1206 |
Topical application of fluoride varnish |
19,953 |
19,807 |
$393K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,868 |
21,644 |
$360K |
| D0220 |
Intraoral - periapical first radiographic image |
22,829 |
22,546 |
$289K |
| D1110 |
Prophylaxis - adult |
5,558 |
5,499 |
$254K |
| D0272 |
Bitewings - two radiographic images |
10,033 |
9,937 |
$213K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,137 |
1,096 |
$205K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,926 |
1,301 |
$195K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,896 |
4,708 |
$152K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,411 |
2,386 |
$97K |
| D0274 |
Bitewings - four radiographic images |
2,926 |
2,877 |
$89K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,627 |
2,599 |
$84K |
| D0140 |
Limited oral evaluation - problem focused |
1,599 |
1,559 |
$54K |
| D1351 |
Sealant - per tooth |
1,542 |
437 |
$54K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
625 |
322 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,121 |
3,977 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
426 |
426 |
$14K |
| D1354 |
|
1,225 |
274 |
$10K |
| D0350 |
|
26 |
26 |
$3K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$3K |
| D9420 |
|
12 |
12 |
$1K |