| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,485 |
485 |
$135K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
896 |
134 |
$125K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,697 |
3,593 |
$124K |
| D1120 |
Prophylaxis - child |
2,651 |
2,566 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,114 |
3,016 |
$83K |
| D0145 |
Oral evaluation for a patient under three years of age |
612 |
601 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,396 |
3,291 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
4,059 |
3,773 |
$44K |
| D9248 |
|
343 |
317 |
$36K |
| D1110 |
Prophylaxis - adult |
637 |
619 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
386 |
80 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
363 |
112 |
$27K |
| D0274 |
Bitewings - four radiographic images |
658 |
637 |
$21K |
| D0350 |
|
1,432 |
1,316 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
323 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
56 |
$9K |
| D0272 |
Bitewings - two radiographic images |
439 |
430 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
362 |
339 |
$9K |
| D1351 |
Sealant - per tooth |
216 |
42 |
$5K |
| D0330 |
Panoramic radiographic image |
159 |
157 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
45 |
$865.56 |
| D0160 |
|
55 |
55 |
$762.45 |
| D9420 |
|
13 |
13 |
$432.93 |
| D0170 |
|
12 |
12 |
$49.61 |
| D0602 |
|
2,977 |
2,862 |
$0.00 |
| D0603 |
|
1,265 |
1,238 |
$0.00 |