| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,291 |
1,773 |
$595K |
| D0120 |
Periodic oral evaluation - established patient |
8,437 |
8,421 |
$185K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,665 |
737 |
$177K |
| D1110 |
Prophylaxis - adult |
3,935 |
3,931 |
$159K |
| D1206 |
Topical application of fluoride varnish |
9,510 |
9,492 |
$158K |
| D1120 |
Prophylaxis - child |
4,797 |
4,785 |
$145K |
| D0220 |
Intraoral - periapical first radiographic image |
8,357 |
8,324 |
$101K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
575 |
344 |
$96K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,407 |
2,340 |
$73K |
| D0272 |
Bitewings - two radiographic images |
3,500 |
3,495 |
$71K |
| D1351 |
Sealant - per tooth |
1,111 |
410 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
184 |
66 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
99 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
405 |
405 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
368 |
363 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
267 |
$10K |
| D0274 |
Bitewings - four radiographic images |
323 |
322 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
44 |
17 |
$4K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$905.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
72 |
$857.38 |
| D7111 |
|
17 |
13 |
$827.39 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$604.51 |
| D0270 |
|
15 |
15 |
$190.35 |