| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,162 |
1,157 |
$111K |
| D1120 |
Prophylaxis - child |
2,569 |
2,569 |
$80K |
| D1206 |
Topical application of fluoride varnish |
2,764 |
2,757 |
$62K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,207 |
1,067 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,721 |
1,721 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
469 |
353 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
492 |
360 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
398 |
332 |
$26K |
| D1351 |
Sealant - per tooth |
808 |
331 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
661 |
445 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,709 |
1,708 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
861 |
861 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
611 |
436 |
$17K |
| D1110 |
Prophylaxis - adult |
189 |
189 |
$8K |
| D2332 |
|
101 |
82 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
521 |
517 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
167 |
167 |
$4K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$3K |
| D0274 |
Bitewings - four radiographic images |
135 |
135 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
97 |
$974.13 |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$821.10 |
| D1354 |
|
48 |
14 |
$720.00 |
| D9310 |
|
12 |
12 |
$637.68 |
| D7111 |
|
14 |
12 |
$295.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
30 |
$102.00 |