| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,493 |
806 |
$187K |
| D1120 |
Prophylaxis - child |
4,217 |
4,151 |
$157K |
| D0120 |
Periodic oral evaluation - established patient |
5,711 |
5,639 |
$143K |
| D1206 |
Topical application of fluoride varnish |
5,857 |
5,771 |
$124K |
| D1351 |
Sealant - per tooth |
2,628 |
730 |
$100K |
| D1110 |
Prophylaxis - adult |
1,745 |
1,730 |
$88K |
| D3120 |
|
2,164 |
882 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
832 |
568 |
$81K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
456 |
296 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,485 |
1,427 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
853 |
827 |
$35K |
| D9110 |
|
627 |
606 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,588 |
1,567 |
$34K |
| D0350 |
|
336 |
336 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
380 |
252 |
$31K |
| D0240 |
|
711 |
681 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,104 |
2,060 |
$27K |
| D0274 |
Bitewings - four radiographic images |
841 |
832 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
233 |
173 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,434 |
1,428 |
$21K |
| D0330 |
Panoramic radiographic image |
379 |
379 |
$21K |
| D1353 |
|
222 |
74 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
64 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$183.87 |