| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,650 |
917 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
3,662 |
3,649 |
$94K |
| D1120 |
Prophylaxis - child |
3,693 |
3,684 |
$90K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
733 |
298 |
$75K |
| D1206 |
Topical application of fluoride varnish |
4,619 |
4,601 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,484 |
1,477 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
841 |
433 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,227 |
2,330 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
613 |
442 |
$42K |
| D1110 |
Prophylaxis - adult |
995 |
990 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,844 |
2,807 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,000 |
970 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,555 |
1,547 |
$27K |
| D0330 |
Panoramic radiographic image |
643 |
641 |
$23K |
| D0274 |
Bitewings - four radiographic images |
706 |
699 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
340 |
330 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
101 |
81 |
$8K |
| D1351 |
Sealant - per tooth |
234 |
81 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
62 |
$5K |
| D2330 |
|
44 |
26 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
17 |
$2K |