| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,407 |
693 |
$134K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
491 |
211 |
$98K |
| D1351 |
Sealant - per tooth |
2,481 |
623 |
$96K |
| D1120 |
Prophylaxis - child |
2,720 |
2,661 |
$95K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,192 |
3,120 |
$90K |
| D7140 |
Extraction, erupted tooth or exposed root |
772 |
399 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,411 |
2,360 |
$75K |
| D0240 |
|
2,798 |
1,307 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,173 |
1,142 |
$52K |
| D1354 |
|
1,927 |
528 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
491 |
293 |
$43K |
| D1110 |
Prophylaxis - adult |
574 |
557 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
285 |
138 |
$34K |
| D0330 |
Panoramic radiographic image |
459 |
454 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
269 |
175 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,582 |
1,546 |
$28K |
| D0274 |
Bitewings - four radiographic images |
469 |
451 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
190 |
190 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
178 |
$8K |
| D1206 |
Topical application of fluoride varnish |
291 |
284 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
182 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
85 |
$1K |