| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,806 |
902 |
$184K |
| D1120 |
Prophylaxis - child |
3,945 |
3,861 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
4,083 |
4,039 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,632 |
4,541 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
828 |
542 |
$63K |
| D1351 |
Sealant - per tooth |
2,131 |
682 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
388 |
191 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
730 |
399 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
953 |
846 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,775 |
1,742 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
664 |
621 |
$24K |
| D1110 |
Prophylaxis - adult |
609 |
601 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
225 |
112 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,346 |
1,277 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,492 |
625 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
319 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
154 |
103 |
$12K |
| D0330 |
Panoramic radiographic image |
177 |
173 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
54 |
$8K |
| D2331 |
|
83 |
56 |
$6K |
| D9420 |
|
40 |
36 |
$4K |
| D0274 |
Bitewings - four radiographic images |
140 |
138 |
$4K |
| D1510 |
|
15 |
12 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
13 |
$494.13 |
| D1206 |
Topical application of fluoride varnish |
15 |
13 |
$218.14 |