| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,248 |
1,958 |
$372K |
| D1351 |
Sealant - per tooth |
10,400 |
1,796 |
$270K |
| D0120 |
Periodic oral evaluation - established patient |
9,829 |
9,627 |
$270K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,918 |
1,874 |
$256K |
| D1110 |
Prophylaxis - adult |
4,601 |
4,506 |
$239K |
| D1120 |
Prophylaxis - child |
6,793 |
6,647 |
$237K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,581 |
1,394 |
$177K |
| D0274 |
Bitewings - four radiographic images |
4,859 |
4,781 |
$159K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,049 |
10,816 |
$152K |
| D0272 |
Bitewings - two radiographic images |
4,729 |
4,649 |
$79K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,802 |
3,657 |
$72K |
| D0210 |
Intraoral - complete series of radiographic images |
1,081 |
1,060 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
4,444 |
4,319 |
$52K |
| D0330 |
Panoramic radiographic image |
1,631 |
1,614 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,388 |
1,361 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
675 |
462 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
140 |
104 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
681 |
660 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
27 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
92 |
54 |
$8K |
| D1206 |
Topical application of fluoride varnish |
412 |
408 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
178 |
165 |
$4K |
| D9248 |
|
14 |
13 |
$1K |
| D2330 |
|
22 |
12 |
$909.72 |
| D0350 |
|
27 |
27 |
$257.32 |
| D0602 |
|
6,380 |
6,329 |
$0.00 |
| D0601 |
|
5,167 |
4,966 |
$0.00 |
| D0603 |
|
1,642 |
1,627 |
$0.00 |