| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,856 |
1,788 |
$300K |
| D1120 |
Prophylaxis - child |
5,006 |
4,992 |
$224K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,219 |
638 |
$210K |
| D0120 |
Periodic oral evaluation - established patient |
4,056 |
4,045 |
$181K |
| D1206 |
Topical application of fluoride varnish |
5,037 |
5,016 |
$160K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,163 |
883 |
$139K |
| D0272 |
Bitewings - two radiographic images |
4,002 |
3,979 |
$132K |
| D1351 |
Sealant - per tooth |
2,090 |
700 |
$92K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
744 |
397 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
704 |
488 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
931 |
923 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,527 |
1,414 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
232 |
158 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,917 |
1,860 |
$27K |
| D0603 |
|
2,841 |
2,797 |
$24K |
| D2332 |
|
123 |
83 |
$12K |
| D0330 |
Panoramic radiographic image |
131 |
128 |
$9K |
| D9920 |
|
176 |
170 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
159 |
$7K |
| D0240 |
|
298 |
295 |
$6K |
| D9430 |
|
161 |
155 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
240 |
226 |
$4K |
| D1354 |
|
369 |
89 |
$4K |
| D0274 |
Bitewings - four radiographic images |
106 |
103 |
$3K |
| D2394 |
|
14 |
13 |
$2K |
| D2330 |
|
18 |
14 |
$2K |
| D0191 |
|
18 |
17 |
$440.00 |
| D9995 |
|
18 |
17 |
$435.00 |
| D0602 |
|
31 |
31 |
$310.00 |
| D0350 |
|
80 |
79 |
$285.00 |
| D1330 |
|
296 |
278 |
$0.00 |