| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,167 |
634 |
$17K |
| D1120 |
Prophylaxis - child |
2,801 |
2,757 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
864 |
326 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
461 |
174 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
930 |
907 |
$3K |
| D0272 |
Bitewings - two radiographic images |
2,083 |
2,050 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
431 |
173 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,651 |
2,509 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,058 |
2,018 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,536 |
1,512 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,493 |
2,282 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
378 |
369 |
$1K |
| D1206 |
Topical application of fluoride varnish |
944 |
936 |
$1K |
| D0330 |
Panoramic radiographic image |
416 |
406 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
115 |
$1K |
| D7962 |
|
57 |
43 |
$1K |
| D1351 |
Sealant - per tooth |
396 |
146 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
347 |
319 |
$776.05 |
| D2330 |
|
75 |
31 |
$636.45 |
| D2332 |
|
66 |
37 |
$484.76 |
| D7961 |
|
25 |
24 |
$452.36 |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$422.42 |
| D7960 |
|
27 |
26 |
$388.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
28 |
$326.45 |
| D0140 |
Limited oral evaluation - problem focused |
101 |
100 |
$276.89 |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$258.97 |
| D9248 |
|
13 |
13 |
$46.63 |
| D9993 |
|
14 |
13 |
$0.00 |
| D0603 |
|
63 |
52 |
$0.00 |