| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
636 |
569 |
$75K |
| D1120 |
Prophylaxis - child |
1,862 |
1,862 |
$56K |
| D1351 |
Sealant - per tooth |
365 |
322 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,398 |
1,398 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
356 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,206 |
1,181 |
$26K |
| D0240 |
|
1,163 |
1,162 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,373 |
1,373 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
154 |
142 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
340 |
315 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
637 |
637 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
914 |
914 |
$10K |
| D1354 |
|
118 |
101 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
69 |
66 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
73 |
67 |
$5K |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
281 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
188 |
184 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
107 |
$858.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
62 |
$315.52 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
16 |
$0.00 |