| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,118 |
894 |
$44K |
| D1120 |
Prophylaxis - child |
3,378 |
3,280 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
3,995 |
3,891 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,499 |
715 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
673 |
290 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
833 |
337 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,786 |
3,682 |
$16K |
| D0272 |
Bitewings - two radiographic images |
2,741 |
2,648 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
562 |
551 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
2,558 |
2,393 |
$8K |
| D1110 |
Prophylaxis - adult |
669 |
655 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,375 |
1,916 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
152 |
101 |
$4K |
| D9248 |
|
320 |
261 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
754 |
671 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
102 |
$3K |
| D0274 |
Bitewings - four radiographic images |
493 |
481 |
$2K |
| D1206 |
Topical application of fluoride varnish |
524 |
515 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
265 |
252 |
$1K |
| D0330 |
Panoramic radiographic image |
125 |
122 |
$1K |
| D2330 |
|
22 |
12 |
$367.80 |
| D1351 |
Sealant - per tooth |
206 |
64 |
$233.82 |