| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
670 |
335 |
$67K |
| D1120 |
Prophylaxis - child |
2,012 |
1,903 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,584 |
1,506 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
574 |
218 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,197 |
2,075 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
671 |
582 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
173 |
45 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
385 |
$17K |
| D0272 |
Bitewings - two radiographic images |
801 |
745 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
71 |
$8K |
| D0240 |
|
380 |
259 |
$7K |
| D1110 |
Prophylaxis - adult |
135 |
125 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
304 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
117 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
85 |
32 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
71 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$335.50 |
| D1999 |
|
192 |
181 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$0.00 |