| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,742 |
4,672 |
$702K |
| D1120 |
Prophylaxis - child |
14,810 |
14,798 |
$653K |
| D0120 |
Periodic oral evaluation - established patient |
20,473 |
20,459 |
$625K |
| D1110 |
Prophylaxis - adult |
7,277 |
7,273 |
$434K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,049 |
2,627 |
$247K |
| D1351 |
Sealant - per tooth |
2,864 |
2,000 |
$240K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,114 |
16,100 |
$225K |
| D1206 |
Topical application of fluoride varnish |
5,745 |
5,745 |
$172K |
| D0274 |
Bitewings - four radiographic images |
5,063 |
5,060 |
$155K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,065 |
974 |
$128K |
| D0272 |
Bitewings - two radiographic images |
6,008 |
6,007 |
$109K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,144 |
1,006 |
$89K |
| D9990 |
|
3,965 |
3,959 |
$87K |
| D0330 |
Panoramic radiographic image |
1,418 |
1,417 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,330 |
1,330 |
$39K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
219 |
205 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
708 |
706 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
369 |
347 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
441 |
440 |
$6K |
| D2330 |
|
43 |
40 |
$4K |
| D2331 |
|
27 |
26 |
$3K |
| D9110 |
|
30 |
30 |
$870.00 |
| D9996 |
|
17 |
17 |
$213.52 |