| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
265 |
164 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
365 |
365 |
$12K |
| D4346 |
|
91 |
91 |
$11K |
| D1120 |
Prophylaxis - child |
329 |
329 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
546 |
546 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
113 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
62 |
$7K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$7K |
| D0274 |
Bitewings - four radiographic images |
209 |
209 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
514 |
514 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
213 |
205 |
$6K |
| D0272 |
Bitewings - two radiographic images |
258 |
258 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
48 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
37 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
194 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
463 |
$4K |
| D2335 |
|
22 |
17 |
$3K |
| D2332 |
|
21 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
95 |
32 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
22 |
$2K |
| D2330 |
|
26 |
18 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$2K |
| D2331 |
|
17 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
21 |
$1K |
| D0240 |
|
50 |
50 |
$1K |
| D9110 |
|
18 |
18 |
$909.50 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
21 |
$595.77 |
| D0270 |
|
22 |
22 |
$216.04 |