| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,248 |
3,172 |
$680K |
| D1120 |
Prophylaxis - child |
9,549 |
9,398 |
$440K |
| D9248 |
|
2,254 |
2,042 |
$411K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,305 |
1,793 |
$394K |
| D1351 |
Sealant - per tooth |
8,952 |
2,451 |
$322K |
| D1206 |
Topical application of fluoride varnish |
12,082 |
11,889 |
$304K |
| D0120 |
Periodic oral evaluation - established patient |
8,351 |
8,247 |
$259K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,159 |
729 |
$188K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,095 |
3,019 |
$165K |
| D0272 |
Bitewings - two radiographic images |
6,525 |
6,429 |
$104K |
| D0330 |
Panoramic radiographic image |
2,192 |
2,145 |
$97K |
| D1110 |
Prophylaxis - adult |
1,354 |
1,332 |
$87K |
| D0140 |
Limited oral evaluation - problem focused |
1,696 |
1,635 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
658 |
487 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,939 |
2,603 |
$56K |
| D1330 |
|
6,050 |
5,941 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
222 |
177 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,451 |
1,429 |
$34K |
| D3120 |
|
547 |
407 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
493 |
491 |
$6K |
| D0240 |
|
283 |
278 |
$5K |
| D4341 |
|
38 |
12 |
$3K |
| D9310 |
|
62 |
62 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$900.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$157.44 |