| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,165 |
626 |
$78K |
| D1120 |
Prophylaxis - child |
2,701 |
2,669 |
$57K |
| D9920 |
|
1,389 |
1,268 |
$50K |
| D1206 |
Topical application of fluoride varnish |
3,062 |
3,029 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,097 |
877 |
$27K |
| D1351 |
Sealant - per tooth |
1,112 |
308 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,933 |
1,914 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
297 |
140 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
818 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
344 |
192 |
$19K |
| D0330 |
Panoramic radiographic image |
328 |
328 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
132 |
64 |
$7K |
| D1110 |
Prophylaxis - adult |
220 |
215 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
462 |
450 |
$6K |
| D9310 |
|
74 |
67 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
801 |
779 |
$5K |
| D0251 |
|
229 |
229 |
$5K |
| D3120 |
|
464 |
262 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
477 |
196 |
$3K |
| D0272 |
Bitewings - two radiographic images |
123 |
123 |
$895.40 |
| D0240 |
|
76 |
40 |
$366.85 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
12 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
30 |
$0.00 |