| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
911 |
471 |
$77K |
| D1120 |
Prophylaxis - child |
1,769 |
1,710 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,038 |
1,960 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,268 |
2,188 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
237 |
70 |
$28K |
| D1110 |
Prophylaxis - adult |
741 |
707 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
392 |
275 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
859 |
742 |
$16K |
| D1351 |
Sealant - per tooth |
617 |
193 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
268 |
135 |
$15K |
| D0272 |
Bitewings - two radiographic images |
805 |
782 |
$13K |
| D0274 |
Bitewings - four radiographic images |
345 |
334 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
296 |
290 |
$8K |
| D0330 |
Panoramic radiographic image |
230 |
223 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
142 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
212 |
203 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
42 |
$5K |
| D0240 |
|
252 |
129 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
158 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
33 |
$347.82 |
| D9410 |
|
12 |
12 |
$202.60 |