| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,162 |
883 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,617 |
2,614 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,164 |
936 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
705 |
251 |
$41K |
| D0274 |
Bitewings - four radiographic images |
2,229 |
2,227 |
$38K |
| D1120 |
Prophylaxis - child |
2,314 |
2,311 |
$36K |
| D1206 |
Topical application of fluoride varnish |
3,014 |
3,011 |
$31K |
| D1110 |
Prophylaxis - adult |
862 |
862 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
537 |
537 |
$16K |
| D0330 |
Panoramic radiographic image |
644 |
644 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
307 |
138 |
$11K |
| D1351 |
Sealant - per tooth |
517 |
191 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
995 |
991 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
77 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
927 |
548 |
$7K |
| D0272 |
Bitewings - two radiographic images |
501 |
501 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
304 |
300 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
99 |
55 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
193 |
193 |
$4K |
| D2331 |
|
84 |
61 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
117 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
28 |
$469.00 |
| D0240 |
|
41 |
40 |
$262.00 |
| D7111 |
|
14 |
12 |
$234.00 |