| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,497 |
765 |
$160K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
945 |
188 |
$126K |
| D1120 |
Prophylaxis - child |
4,383 |
4,284 |
$121K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,930 |
1,748 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,187 |
3,149 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,798 |
1,589 |
$58K |
| D1206 |
Topical application of fluoride varnish |
3,195 |
3,086 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
992 |
952 |
$44K |
| D1351 |
Sealant - per tooth |
1,200 |
342 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,031 |
1,964 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
203 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,630 |
1,621 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
401 |
185 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
459 |
444 |
$18K |
| D9420 |
|
162 |
138 |
$17K |
| D1110 |
Prophylaxis - adult |
353 |
347 |
$14K |
| D0330 |
Panoramic radiographic image |
235 |
233 |
$14K |
| D0272 |
Bitewings - two radiographic images |
607 |
601 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
267 |
251 |
$9K |
| D0240 |
|
217 |
111 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
13 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$469.70 |