| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,100 |
630 |
$35K |
| D1120 |
Prophylaxis - child |
3,074 |
2,985 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,882 |
1,845 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
690 |
267 |
$12K |
| D0272 |
Bitewings - two radiographic images |
2,236 |
2,148 |
$10K |
| D1206 |
Topical application of fluoride varnish |
1,056 |
1,042 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
2,905 |
2,682 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
868 |
832 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,243 |
2,161 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,037 |
2,514 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
154 |
42 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
469 |
423 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
266 |
249 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
114 |
102 |
$2K |
| D1351 |
Sealant - per tooth |
361 |
117 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
24 |
$1K |
| D7962 |
|
15 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
333 |
286 |
$815.38 |
| D7961 |
|
14 |
14 |
$776.44 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
78 |
28 |
$727.43 |
| D0140 |
Limited oral evaluation - problem focused |
35 |
29 |
$450.69 |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$293.52 |
| D2332 |
|
22 |
12 |
$221.88 |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$0.00 |
| D9993 |
|
20 |
20 |
$0.00 |
| D0350 |
|
441 |
89 |
$0.00 |
| D1330 |
|
400 |
397 |
$0.00 |
| D1310 |
|
55 |
52 |
$0.00 |
| D0603 |
|
25 |
25 |
$0.00 |