| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,630 |
860 |
$156K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,279 |
517 |
$147K |
| D1120 |
Prophylaxis - child |
6,708 |
4,368 |
$121K |
| D1206 |
Topical application of fluoride varnish |
5,117 |
3,820 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
5,055 |
3,078 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
879 |
542 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
918 |
485 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,315 |
1,113 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,520 |
1,151 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,896 |
1,387 |
$30K |
| D9310 |
|
616 |
515 |
$27K |
| D1351 |
Sealant - per tooth |
912 |
186 |
$23K |
| D0330 |
Panoramic radiographic image |
315 |
288 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
443 |
367 |
$16K |
| D2330 |
|
237 |
114 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
845 |
725 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
88 |
50 |
$7K |
| D9248 |
|
196 |
137 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,494 |
419 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
52 |
$660.48 |
| D1110 |
Prophylaxis - adult |
69 |
12 |
$0.00 |