| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,367 |
561 |
$339K |
| D1120 |
Prophylaxis - child |
4,783 |
4,702 |
$257K |
| D1206 |
Topical application of fluoride varnish |
5,335 |
5,250 |
$172K |
| D1351 |
Sealant - per tooth |
4,024 |
767 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
3,350 |
3,280 |
$144K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
581 |
293 |
$116K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,122 |
1,085 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,334 |
1,292 |
$82K |
| D0272 |
Bitewings - two radiographic images |
1,782 |
1,747 |
$65K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
159 |
64 |
$45K |
| D1110 |
Prophylaxis - adult |
437 |
433 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,296 |
1,270 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
453 |
432 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,059 |
1,004 |
$21K |
| D0274 |
Bitewings - four radiographic images |
277 |
276 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
251 |
248 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
38 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
34 |
12 |
$6K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$1K |
| D0601 |
|
338 |
329 |
$0.00 |
| D0603 |
|
4,799 |
4,746 |
$0.00 |