| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,806 |
3,562 |
$606K |
| D1120 |
Prophylaxis - child |
14,315 |
14,315 |
$501K |
| D0120 |
Periodic oral evaluation - established patient |
20,108 |
20,108 |
$473K |
| D1206 |
Topical application of fluoride varnish |
20,953 |
20,953 |
$345K |
| D1110 |
Prophylaxis - adult |
6,346 |
6,346 |
$321K |
| D1351 |
Sealant - per tooth |
8,583 |
2,527 |
$259K |
| D0272 |
Bitewings - two radiographic images |
11,663 |
11,663 |
$222K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,538 |
2,078 |
$218K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,336 |
1,503 |
$214K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,589 |
915 |
$206K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,424 |
5,321 |
$176K |
| D0140 |
Limited oral evaluation - problem focused |
2,459 |
2,437 |
$95K |
| D0330 |
Panoramic radiographic image |
2,013 |
2,012 |
$93K |
| D0220 |
Intraoral - periapical first radiographic image |
6,662 |
6,586 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,760 |
2,758 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
868 |
868 |
$36K |
| D0145 |
Oral evaluation for a patient under three years of age |
612 |
612 |
$27K |
| D2330 |
|
228 |
160 |
$16K |
| D7111 |
|
236 |
153 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
188 |
129 |
$15K |
| D0274 |
Bitewings - four radiographic images |
435 |
435 |
$13K |
| D2331 |
|
97 |
65 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
38 |
$5K |
| D9248 |
|
40 |
40 |
$3K |
| D9420 |
|
25 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$696.60 |