| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,537 |
2,384 |
$442K |
| D1120 |
Prophylaxis - child |
9,913 |
9,910 |
$418K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,080 |
1,349 |
$390K |
| D0120 |
Periodic oral evaluation - established patient |
9,578 |
9,577 |
$324K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,671 |
10,668 |
$297K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,863 |
2,064 |
$272K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,010 |
1,250 |
$176K |
| D1351 |
Sealant - per tooth |
4,444 |
1,766 |
$143K |
| D0272 |
Bitewings - two radiographic images |
4,022 |
4,022 |
$103K |
| D0140 |
Limited oral evaluation - problem focused |
1,313 |
1,302 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
3,683 |
3,638 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,811 |
1,921 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
883 |
882 |
$54K |
| D1110 |
Prophylaxis - adult |
721 |
721 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
290 |
214 |
$38K |
| D0330 |
Panoramic radiographic image |
484 |
484 |
$38K |
| D0240 |
|
1,738 |
926 |
$37K |
| D0274 |
Bitewings - four radiographic images |
413 |
413 |
$15K |
| D2330 |
|
37 |
27 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$2K |
| D2331 |
|
16 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$602.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
423 |
349 |
$0.00 |