| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
695 |
279 |
$61K |
| D1120 |
Prophylaxis - child |
1,485 |
1,325 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
317 |
88 |
$42K |
| D1351 |
Sealant - per tooth |
1,683 |
338 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,451 |
1,296 |
$35K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
305 |
83 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
933 |
761 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,768 |
1,571 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
127 |
122 |
$17K |
| D0272 |
Bitewings - two radiographic images |
904 |
812 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,703 |
1,416 |
$15K |
| D1206 |
Topical application of fluoride varnish |
1,000 |
870 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
675 |
640 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
130 |
$4K |
| D0274 |
Bitewings - four radiographic images |
166 |
149 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
16 |
$1K |
| D1110 |
Prophylaxis - adult |
18 |
12 |
$439.04 |
| D0330 |
Panoramic radiographic image |
29 |
27 |
$280.68 |
| D0601 |
|
380 |
366 |
$0.00 |
| D0603 |
|
1,648 |
1,543 |
$0.00 |
| D0602 |
|
32 |
31 |
$0.00 |