| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,676 |
1,091 |
$24K |
| D1120 |
Prophylaxis - child |
5,799 |
5,692 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
510 |
192 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
611 |
343 |
$9K |
| D1206 |
Topical application of fluoride varnish |
5,453 |
5,334 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
6,313 |
6,214 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
491 |
179 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
7,770 |
7,441 |
$5K |
| D0272 |
Bitewings - two radiographic images |
4,264 |
4,147 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,134 |
6,839 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
999 |
978 |
$4K |
| D1110 |
Prophylaxis - adult |
1,951 |
1,900 |
$4K |
| D0274 |
Bitewings - four radiographic images |
2,647 |
2,526 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
205 |
96 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
110 |
$1K |
| D0330 |
Panoramic radiographic image |
822 |
727 |
$729.39 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
304 |
262 |
$720.16 |
| D0140 |
Limited oral evaluation - problem focused |
389 |
347 |
$623.09 |
| D1351 |
Sealant - per tooth |
216 |
67 |
$318.55 |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
33 |
$89.88 |
| D0210 |
Intraoral - complete series of radiographic images |
303 |
291 |
$47.00 |
| D0601 |
|
573 |
562 |
$0.00 |
| D0602 |
|
522 |
504 |
$0.00 |
| D0603 |
|
365 |
351 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,068 |
2,061 |
$0.00 |