| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,307 |
1,207 |
$294K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,255 |
928 |
$159K |
| D1120 |
Prophylaxis - child |
4,222 |
3,749 |
$101K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,457 |
1,893 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,604 |
2,118 |
$95K |
| D1351 |
Sealant - per tooth |
3,834 |
889 |
$89K |
| D1206 |
Topical application of fluoride varnish |
5,326 |
4,687 |
$76K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
767 |
184 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,900 |
2,713 |
$71K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,357 |
498 |
$69K |
| D8670 |
Periodic orthodontic treatment visit |
991 |
764 |
$66K |
| D1110 |
Prophylaxis - adult |
1,233 |
1,077 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,777 |
2,202 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,307 |
1,665 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,954 |
1,645 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
835 |
713 |
$27K |
| D0330 |
Panoramic radiographic image |
723 |
572 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
224 |
105 |
$23K |
| D0274 |
Bitewings - four radiographic images |
731 |
627 |
$18K |
| D0240 |
|
981 |
437 |
$13K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
16 |
12 |
$10K |
| D1510 |
|
43 |
26 |
$8K |
| D1354 |
|
832 |
229 |
$5K |
| D9420 |
|
96 |
47 |
$4K |
| D2330 |
|
63 |
24 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
80 |
17 |
$2K |
| D0470 |
|
81 |
74 |
$1K |
| D0340 |
|
70 |
65 |
$1K |