| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,726 |
952 |
$105K |
| D1110 |
Prophylaxis - adult |
2,868 |
2,849 |
$99K |
| D1351 |
Sealant - per tooth |
2,910 |
514 |
$72K |
| D0330 |
Panoramic radiographic image |
1,622 |
1,613 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
3,397 |
3,368 |
$65K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
192 |
123 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
789 |
477 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
477 |
335 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,601 |
1,595 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,276 |
1,262 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,626 |
1,622 |
$31K |
| D1120 |
Prophylaxis - child |
976 |
974 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,846 |
1,839 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
388 |
166 |
$24K |
| D1330 |
|
2,302 |
2,276 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
312 |
50 |
$22K |
| D1310 |
|
1,936 |
1,915 |
$20K |
| D2332 |
|
221 |
126 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,894 |
1,795 |
$12K |
| D1206 |
Topical application of fluoride varnish |
579 |
563 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
26 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
615 |
561 |
$6K |
| D5110 |
|
12 |
12 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
94 |
88 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D2330 |
|
28 |
16 |
$1K |