| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
246 |
144 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
326 |
$11K |
| D1120 |
Prophylaxis - child |
297 |
297 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
496 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
101 |
$9K |
| D4346 |
|
60 |
60 |
$7K |
| D1110 |
Prophylaxis - adult |
153 |
153 |
$7K |
| D0274 |
Bitewings - four radiographic images |
213 |
213 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
43 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
46 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
474 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
177 |
168 |
$5K |
| D0272 |
Bitewings - two radiographic images |
220 |
220 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
190 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
443 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
26 |
$3K |
| D1351 |
Sealant - per tooth |
95 |
30 |
$2K |
| D2330 |
|
21 |
14 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
16 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$825.44 |
| D0240 |
|
33 |
33 |
$720.72 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
21 |
$595.77 |
| D0270 |
|
12 |
12 |
$117.84 |