| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,201 |
1,537 |
$401K |
| D1120 |
Prophylaxis - child |
10,171 |
9,187 |
$378K |
| D0120 |
Periodic oral evaluation - established patient |
7,409 |
6,819 |
$207K |
| D1310 |
|
5,239 |
4,731 |
$198K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,522 |
597 |
$195K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,568 |
1,281 |
$186K |
| D9630 |
|
11,032 |
9,308 |
$162K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,359 |
3,498 |
$146K |
| D1351 |
Sealant - per tooth |
4,477 |
1,298 |
$131K |
| D0603 |
|
12,899 |
11,391 |
$127K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,174 |
5,548 |
$120K |
| D1330 |
|
5,236 |
4,732 |
$116K |
| D1206 |
Topical application of fluoride varnish |
5,259 |
4,690 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,288 |
668 |
$94K |
| D0330 |
Panoramic radiographic image |
1,544 |
1,363 |
$88K |
| D0272 |
Bitewings - two radiographic images |
3,613 |
3,306 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,235 |
1,920 |
$80K |
| D0425 |
|
1,816 |
1,651 |
$74K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,955 |
1,759 |
$69K |
| D1110 |
Prophylaxis - adult |
1,231 |
1,122 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
3,008 |
2,693 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
1,281 |
1,117 |
$46K |
| D0240 |
|
1,562 |
1,360 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,872 |
1,135 |
$28K |
| D0274 |
Bitewings - four radiographic images |
702 |
634 |
$26K |
| D3120 |
|
576 |
332 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
82 |
36 |
$6K |
| D7970 |
|
16 |
13 |
$4K |
| D1999 |
|
1,593 |
1,448 |
$3K |
| D0602 |
|
272 |
227 |
$2K |
| D0601 |
|
76 |
71 |
$744.93 |
| D0270 |
|
14 |
12 |
$245.70 |
| D4999 |
|
1,513 |
1,341 |
$0.00 |
| D0009 |
|
51 |
51 |
$0.00 |