| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,359 |
544 |
$99K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
652 |
270 |
$74K |
| D9248 |
|
677 |
663 |
$58K |
| D1120 |
Prophylaxis - child |
1,724 |
1,719 |
$57K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
653 |
258 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
948 |
414 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,297 |
2,286 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
811 |
424 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,479 |
1,468 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
923 |
921 |
$27K |
| D1110 |
Prophylaxis - adult |
662 |
655 |
$26K |
| D1351 |
Sealant - per tooth |
770 |
252 |
$24K |
| D0330 |
Panoramic radiographic image |
727 |
721 |
$24K |
| D0272 |
Bitewings - two radiographic images |
870 |
864 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
415 |
404 |
$12K |
| D0274 |
Bitewings - four radiographic images |
454 |
452 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
403 |
401 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
889 |
878 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
728 |
696 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
30 |
$4K |
| D1510 |
|
17 |
14 |
$3K |