| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,038 |
1,888 |
$313K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,179 |
815 |
$254K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,009 |
918 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
4,235 |
4,142 |
$116K |
| D1120 |
Prophylaxis - child |
4,413 |
4,323 |
$110K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,327 |
513 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,269 |
857 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,821 |
3,065 |
$76K |
| D1206 |
Topical application of fluoride varnish |
5,331 |
5,229 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,685 |
1,655 |
$68K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
671 |
485 |
$64K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,853 |
1,779 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,715 |
3,603 |
$40K |
| D1110 |
Prophylaxis - adult |
958 |
940 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,576 |
1,546 |
$25K |
| D0330 |
Panoramic radiographic image |
599 |
596 |
$24K |
| D2332 |
|
280 |
147 |
$23K |
| D0274 |
Bitewings - four radiographic images |
587 |
584 |
$13K |
| D2330 |
|
233 |
142 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
327 |
320 |
$10K |
| D1510 |
|
80 |
52 |
$10K |
| D3120 |
|
80 |
65 |
$2K |
| D1351 |
Sealant - per tooth |
56 |
24 |
$1K |