| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,799 |
1,735 |
$291K |
| D1120 |
Prophylaxis - child |
4,555 |
4,514 |
$201K |
| D0120 |
Periodic oral evaluation - established patient |
4,206 |
4,168 |
$186K |
| D1206 |
Topical application of fluoride varnish |
4,533 |
4,491 |
$142K |
| D0272 |
Bitewings - two radiographic images |
3,702 |
3,657 |
$122K |
| D1351 |
Sealant - per tooth |
2,550 |
767 |
$111K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
498 |
376 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
420 |
320 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
957 |
934 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
173 |
148 |
$20K |
| D0603 |
|
1,847 |
1,828 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
96 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,124 |
1,104 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
232 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
66 |
$9K |
| D9920 |
|
113 |
111 |
$6K |
| D2332 |
|
40 |
31 |
$4K |
| D0240 |
|
112 |
112 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D9995 |
|
15 |
15 |
$375.00 |
| D0191 |
|
15 |
15 |
$345.00 |
| D1110 |
Prophylaxis - adult |
20 |
12 |
$228.00 |