| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,881 |
4,904 |
$815K |
| D1120 |
Prophylaxis - child |
18,400 |
18,400 |
$644K |
| D1110 |
Prophylaxis - adult |
12,644 |
12,644 |
$638K |
| D0120 |
Periodic oral evaluation - established patient |
22,496 |
22,496 |
$525K |
| D1206 |
Topical application of fluoride varnish |
31,016 |
31,016 |
$509K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,813 |
3,313 |
$389K |
| D0274 |
Bitewings - four radiographic images |
12,897 |
12,897 |
$344K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,401 |
6,401 |
$265K |
| D0330 |
Panoramic radiographic image |
5,322 |
5,322 |
$258K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,291 |
6,829 |
$238K |
| D0272 |
Bitewings - two radiographic images |
12,046 |
12,046 |
$219K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,529 |
1,171 |
$198K |
| D1351 |
Sealant - per tooth |
5,788 |
1,868 |
$174K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,076 |
742 |
$134K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,120 |
2,120 |
$94K |
| D0140 |
Limited oral evaluation - problem focused |
1,713 |
1,708 |
$65K |
| D0240 |
|
3,280 |
1,728 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
3,136 |
3,121 |
$40K |
| D7111 |
|
454 |
356 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
212 |
153 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,329 |
1,246 |
$14K |
| D9920 |
|
149 |
138 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
84 |
66 |
$7K |
| D2394 |
|
20 |
17 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$194.40 |