| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,638 |
853 |
$100K |
| D1120 |
Prophylaxis - child |
4,346 |
4,204 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,478 |
3,386 |
$77K |
| D1206 |
Topical application of fluoride varnish |
4,949 |
4,776 |
$73K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
471 |
147 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,298 |
1,248 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
662 |
356 |
$36K |
| D1351 |
Sealant - per tooth |
2,072 |
620 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
589 |
353 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,240 |
1,176 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
1,212 |
1,131 |
$23K |
| D0272 |
Bitewings - two radiographic images |
2,158 |
2,091 |
$21K |
| D1999 |
|
1,832 |
1,655 |
$17K |
| D9999 |
Unspecified adjunctive procedure, by report |
537 |
518 |
$14K |
| D1110 |
Prophylaxis - adult |
402 |
391 |
$12K |
| D0330 |
Panoramic radiographic image |
305 |
291 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,184 |
1,104 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
107 |
42 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
72 |
$8K |
| D0274 |
Bitewings - four radiographic images |
371 |
352 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,221 |
537 |
$3K |
| D0160 |
|
13 |
13 |
$518.16 |
| D0180 |
|
14 |
13 |
$0.00 |
| D3120 |
|
36 |
28 |
$0.00 |