| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,528 |
801 |
$154K |
| D1120 |
Prophylaxis - child |
5,471 |
4,560 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,296 |
2,245 |
$92K |
| D1206 |
Topical application of fluoride varnish |
3,734 |
3,427 |
$82K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
463 |
214 |
$61K |
| D1351 |
Sealant - per tooth |
2,467 |
569 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,620 |
1,481 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
606 |
371 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
2,409 |
1,766 |
$42K |
| D0330 |
Panoramic radiographic image |
791 |
734 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,019 |
1,803 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,104 |
1,041 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
332 |
174 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,227 |
994 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
430 |
389 |
$15K |
| D9248 |
|
277 |
265 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
80 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,135 |
1,045 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
274 |
256 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
748 |
472 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
12 |
$1K |
| D0603 |
|
2,378 |
1,900 |
$0.00 |
| D0602 |
|
175 |
149 |
$0.00 |