| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,808 |
1,498 |
$314K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,629 |
922 |
$297K |
| D1120 |
Prophylaxis - child |
7,332 |
7,332 |
$210K |
| D0120 |
Periodic oral evaluation - established patient |
8,973 |
8,973 |
$180K |
| D1206 |
Topical application of fluoride varnish |
9,352 |
9,350 |
$162K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,696 |
918 |
$106K |
| D1110 |
Prophylaxis - adult |
2,167 |
2,167 |
$95K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
519 |
330 |
$80K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
859 |
482 |
$73K |
| D0330 |
Panoramic radiographic image |
1,529 |
1,529 |
$71K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
256 |
256 |
$65K |
| D0272 |
Bitewings - two radiographic images |
3,510 |
3,510 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,328 |
2,205 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
2,829 |
2,795 |
$41K |
| D1351 |
Sealant - per tooth |
1,690 |
517 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
584 |
444 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,098 |
1,098 |
$31K |
| D0240 |
|
1,197 |
1,196 |
$24K |
| D0350 |
|
719 |
719 |
$20K |
| D9222 |
|
258 |
258 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
605 |
605 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
551 |
546 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,016 |
1,128 |
$15K |
| D3120 |
|
292 |
210 |
$8K |
| D9610 |
|
250 |
250 |
$7K |
| D2934 |
|
41 |
12 |
$7K |
| 00170 |
Anesthesia for intraoral procedures, including biopsy |
13 |
13 |
$4K |
| D1510 |
|
19 |
16 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
69 |
69 |
$2K |
| D2332 |
|
18 |
14 |
$2K |