| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,948 |
1,654 |
$299K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,488 |
443 |
$124K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,225 |
696 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,702 |
978 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
3,802 |
3,729 |
$102K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,277 |
750 |
$74K |
| D1120 |
Prophylaxis - child |
2,945 |
2,889 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,538 |
1,490 |
$67K |
| D1110 |
Prophylaxis - adult |
2,002 |
1,952 |
$64K |
| D1351 |
Sealant - per tooth |
2,974 |
665 |
$64K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,071 |
355 |
$60K |
| D0272 |
Bitewings - two radiographic images |
3,706 |
3,616 |
$59K |
| D0330 |
Panoramic radiographic image |
1,479 |
1,463 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,938 |
3,845 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,332 |
1,235 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
949 |
925 |
$24K |
| D2332 |
|
328 |
191 |
$22K |
| D2335 |
|
231 |
137 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,492 |
1,419 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
474 |
431 |
$14K |
| D1206 |
Topical application of fluoride varnish |
542 |
530 |
$9K |
| D2330 |
|
174 |
127 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
537 |
365 |
$6K |
| D9420 |
|
72 |
70 |
$5K |
| D2740 |
Crown - porcelain/ceramic |
19 |
14 |
$5K |
| D2950 |
|
57 |
41 |
$4K |
| D2933 |
|
84 |
12 |
$4K |
| D1510 |
|
25 |
13 |
$2K |
| D2331 |
|
16 |
12 |
$926.00 |
| D0250 |
|
14 |
14 |
$905.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$840.00 |