| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,131 |
496 |
$149K |
| D1120 |
Prophylaxis - child |
2,806 |
2,510 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
3,405 |
3,063 |
$79K |
| D1206 |
Topical application of fluoride varnish |
3,763 |
3,371 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
548 |
289 |
$52K |
| D1351 |
Sealant - per tooth |
1,525 |
391 |
$51K |
| D1110 |
Prophylaxis - adult |
909 |
809 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
947 |
808 |
$29K |
| D3120 |
|
785 |
303 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
665 |
588 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,151 |
1,018 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
135 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,631 |
1,419 |
$21K |
| D9110 |
|
388 |
332 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,218 |
1,069 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
123 |
79 |
$15K |
| D0274 |
Bitewings - four radiographic images |
384 |
337 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
129 |
77 |
$10K |
| D0330 |
Panoramic radiographic image |
150 |
144 |
$8K |