| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
472 |
248 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
140 |
65 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
224 |
95 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
367 |
333 |
$8K |
| D1120 |
Prophylaxis - child |
377 |
348 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
101 |
68 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
961 |
601 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
127 |
60 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
165 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
712 |
664 |
$6K |
| D1206 |
Topical application of fluoride varnish |
465 |
426 |
$6K |
| D3120 |
|
223 |
130 |
$5K |
| D1351 |
Sealant - per tooth |
285 |
84 |
$4K |
| D0330 |
Panoramic radiographic image |
124 |
119 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
148 |
136 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
42 |
$3K |
| D1110 |
Prophylaxis - adult |
96 |
88 |
$3K |
| D0274 |
Bitewings - four radiographic images |
125 |
124 |
$2K |
| D0272 |
Bitewings - two radiographic images |
183 |
171 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
101 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$446.00 |