| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,374 |
691 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
3,548 |
3,536 |
$72K |
| D1351 |
Sealant - per tooth |
3,276 |
853 |
$61K |
| D1120 |
Prophylaxis - child |
3,217 |
3,204 |
$61K |
| D1206 |
Topical application of fluoride varnish |
4,466 |
4,450 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,336 |
4,207 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
4,526 |
4,492 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
746 |
433 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
387 |
197 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,460 |
2,453 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
799 |
795 |
$28K |
| D1110 |
Prophylaxis - adult |
1,068 |
1,066 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,044 |
1,044 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
593 |
583 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
409 |
255 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
211 |
82 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
256 |
256 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
196 |
$5K |
| D2332 |
|
73 |
44 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$1K |
| D9310 |
|
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
22 |
$505.00 |