| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,628 |
746 |
$145K |
| D1120 |
Prophylaxis - child |
2,644 |
2,644 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,459 |
3,459 |
$71K |
| D1110 |
Prophylaxis - adult |
1,265 |
1,265 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,740 |
3,740 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
400 |
179 |
$48K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
497 |
107 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,623 |
1,479 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,174 |
1,174 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
287 |
64 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
483 |
217 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,781 |
1,762 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
661 |
641 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,475 |
1,214 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
471 |
471 |
$14K |
| D0272 |
Bitewings - two radiographic images |
749 |
749 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
201 |
116 |
$13K |
| D0330 |
Panoramic radiographic image |
232 |
232 |
$11K |
| D0240 |
|
615 |
614 |
$11K |
| D3120 |
|
103 |
45 |
$3K |
| D1351 |
Sealant - per tooth |
40 |
12 |
$929.60 |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$772.45 |