| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,129 |
771 |
$248K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,779 |
661 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
3,796 |
3,689 |
$110K |
| D1206 |
Topical application of fluoride varnish |
5,188 |
4,974 |
$106K |
| D1120 |
Prophylaxis - child |
4,335 |
4,198 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,064 |
1,013 |
$41K |
| D0330 |
Panoramic radiographic image |
917 |
894 |
$35K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,039 |
1,008 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,259 |
1,136 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
163 |
47 |
$25K |
| D0272 |
Bitewings - two radiographic images |
2,199 |
2,137 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,664 |
1,607 |
$14K |
| D1110 |
Prophylaxis - adult |
298 |
294 |
$13K |
| D0240 |
|
1,394 |
701 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
500 |
428 |
$11K |
| D1999 |
|
957 |
808 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,445 |
1,222 |
$5K |
| D0274 |
Bitewings - four radiographic images |
282 |
276 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
27 |
12 |
$738.48 |
| D1354 |
|
167 |
26 |
$663.60 |
| D9920 |
|
15 |
15 |
$272.54 |