| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,221 |
571 |
$157K |
| D1120 |
Prophylaxis - child |
3,036 |
3,035 |
$110K |
| D1206 |
Topical application of fluoride varnish |
3,645 |
3,639 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,356 |
2,356 |
$60K |
| D1351 |
Sealant - per tooth |
1,079 |
337 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
791 |
790 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
275 |
150 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,125 |
1,124 |
$24K |
| D1110 |
Prophylaxis - adult |
437 |
437 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
667 |
646 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,501 |
1,482 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
890 |
888 |
$15K |
| D0330 |
Panoramic radiographic image |
204 |
204 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
55 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
63 |
24 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
146 |
146 |
$5K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D0240 |
|
56 |
56 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
13 |
$2K |
| D0350 |
|
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$427.30 |