| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
175 |
$50K |
| D1120 |
Prophylaxis - child |
676 |
637 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
802 |
755 |
$19K |
| D1206 |
Topical application of fluoride varnish |
873 |
826 |
$15K |
| D1351 |
Sealant - per tooth |
416 |
119 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
304 |
278 |
$10K |
| D1110 |
Prophylaxis - adult |
212 |
203 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
47 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
49 |
$7K |
| D0272 |
Bitewings - two radiographic images |
287 |
273 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
137 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
16 |
$3K |
| D9110 |
|
50 |
48 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
169 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
56 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
14 |
$2K |
| D1353 |
|
36 |
12 |
$1K |
| D3120 |
|
25 |
12 |
$893.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
62 |
$815.60 |