| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,101 |
651 |
$139K |
| D1120 |
Prophylaxis - child |
3,442 |
3,441 |
$116K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
776 |
428 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,157 |
712 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
3,384 |
3,383 |
$95K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,977 |
1,777 |
$93K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,272 |
734 |
$90K |
| D1351 |
Sealant - per tooth |
1,944 |
603 |
$70K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
694 |
393 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,608 |
2,608 |
$49K |
| D2394 |
|
311 |
178 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,237 |
2,237 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,371 |
1,371 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,013 |
3,007 |
$34K |
| D1110 |
Prophylaxis - adult |
683 |
682 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,127 |
1,127 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
778 |
778 |
$22K |
| D1510 |
|
58 |
51 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
937 |
933 |
$11K |
| D2335 |
|
88 |
48 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
28 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$2K |