| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,031 |
1,883 |
$316K |
| D1120 |
Prophylaxis - child |
4,400 |
4,399 |
$197K |
| D0120 |
Periodic oral evaluation - established patient |
3,477 |
3,476 |
$155K |
| D1206 |
Topical application of fluoride varnish |
4,375 |
4,373 |
$139K |
| D0272 |
Bitewings - two radiographic images |
3,403 |
3,399 |
$114K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
887 |
643 |
$84K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
476 |
319 |
$83K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
650 |
528 |
$79K |
| D1351 |
Sealant - per tooth |
1,479 |
573 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
886 |
883 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,340 |
1,235 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
238 |
158 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
214 |
147 |
$25K |
| D0603 |
|
2,327 |
2,306 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,150 |
1,132 |
$16K |
| D2332 |
|
91 |
64 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
121 |
$5K |
| D1354 |
|
448 |
151 |
$4K |
| D9920 |
|
79 |
77 |
$4K |
| D0240 |
|
190 |
189 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
141 |
134 |
$3K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$884.00 |
| D9430 |
|
28 |
27 |
$680.00 |
| D0191 |
|
18 |
18 |
$440.00 |
| D9995 |
|
17 |
17 |
$420.00 |
| D0350 |
|
76 |
76 |
$350.00 |
| D0602 |
|
12 |
12 |
$120.00 |
| D1330 |
|
201 |
190 |
$0.00 |