| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,094 |
723 |
$150K |
| D1120 |
Prophylaxis - child |
2,652 |
2,651 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
2,274 |
2,274 |
$91K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,670 |
2,668 |
$68K |
| D0272 |
Bitewings - two radiographic images |
1,457 |
1,457 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
214 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
527 |
$26K |
| D1351 |
Sealant - per tooth |
455 |
142 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
943 |
939 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
70 |
53 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
694 |
622 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
496 |
496 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
137 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
24 |
$3K |