| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
830 |
529 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
767 |
519 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,855 |
1,830 |
$31K |
| D1351 |
Sealant - per tooth |
1,869 |
457 |
$28K |
| D1120 |
Prophylaxis - child |
1,647 |
1,627 |
$25K |
| D1206 |
Topical application of fluoride varnish |
2,425 |
2,399 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
525 |
514 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,414 |
1,398 |
$14K |
| D0330 |
Panoramic radiographic image |
613 |
612 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
185 |
135 |
$12K |
| D1110 |
Prophylaxis - adult |
597 |
596 |
$11K |
| D0274 |
Bitewings - four radiographic images |
664 |
658 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
287 |
246 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
48 |
38 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
140 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
320 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
16 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
100 |
100 |
$1K |