| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,298 |
800 |
$171K |
| D1120 |
Prophylaxis - child |
2,691 |
2,644 |
$123K |
| D1351 |
Sealant - per tooth |
2,782 |
676 |
$101K |
| D1206 |
Topical application of fluoride varnish |
3,468 |
3,414 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,753 |
2,717 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
661 |
418 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
542 |
318 |
$63K |
| D1110 |
Prophylaxis - adult |
713 |
706 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,635 |
1,438 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
179 |
105 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
487 |
475 |
$26K |
| D0330 |
Panoramic radiographic image |
524 |
518 |
$23K |
| D3120 |
|
590 |
435 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,222 |
1,201 |
$19K |
| D0274 |
Bitewings - four radiographic images |
764 |
757 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
375 |
359 |
$17K |
| D1330 |
|
2,024 |
1,991 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
52 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
466 |
$5K |
| D0240 |
|
147 |
144 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
27 |
$301.76 |