| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,113 |
380 |
$100K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
456 |
124 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,670 |
1,651 |
$46K |
| D1110 |
Prophylaxis - adult |
784 |
771 |
$40K |
| D1120 |
Prophylaxis - child |
926 |
917 |
$32K |
| D0145 |
Oral evaluation for a patient under three years of age |
210 |
210 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
379 |
151 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,624 |
1,608 |
$23K |
| D9248 |
|
212 |
196 |
$23K |
| D0274 |
Bitewings - four radiographic images |
492 |
483 |
$16K |
| D0272 |
Bitewings - two radiographic images |
610 |
599 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
144 |
60 |
$11K |
| D1351 |
Sealant - per tooth |
321 |
70 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
812 |
327 |
$9K |
| D0330 |
Panoramic radiographic image |
224 |
222 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
263 |
247 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
472 |
460 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
29 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
81 |
$2K |
| D7111 |
|
122 |
71 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
31 |
$854.13 |
| D0350 |
|
31 |
31 |
$477.88 |
| D9420 |
|
12 |
12 |
$399.41 |
| D0602 |
|
282 |
280 |
$0.00 |
| D0601 |
|
727 |
725 |
$0.00 |
| D0603 |
|
816 |
810 |
$0.00 |