| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13,466 |
8,825 |
$1.41M |
| D1120 |
Prophylaxis - child |
40,276 |
40,276 |
$1.41M |
| D1206 |
Topical application of fluoride varnish |
59,327 |
59,327 |
$976K |
| D1110 |
Prophylaxis - adult |
18,341 |
18,341 |
$928K |
| D0120 |
Periodic oral evaluation - established patient |
38,003 |
38,003 |
$895K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16,205 |
16,205 |
$671K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17,986 |
17,505 |
$586K |
| D0330 |
Panoramic radiographic image |
11,083 |
11,082 |
$551K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,189 |
4,774 |
$534K |
| D0274 |
Bitewings - four radiographic images |
18,590 |
18,590 |
$492K |
| D0272 |
Bitewings - two radiographic images |
25,239 |
25,239 |
$465K |
| D1351 |
Sealant - per tooth |
13,009 |
3,395 |
$393K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,250 |
1,791 |
$296K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,857 |
1,494 |
$244K |
| D0145 |
Oral evaluation for a patient under three years of age |
4,509 |
4,509 |
$205K |
| D0220 |
Intraoral - periapical first radiographic image |
10,234 |
10,191 |
$131K |
| D0140 |
Limited oral evaluation - problem focused |
2,865 |
2,858 |
$110K |
| D7111 |
|
1,526 |
1,199 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
849 |
663 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,108 |
4,561 |
$51K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
293 |
258 |
$25K |
| D0270 |
|
12 |
12 |
$180.00 |