| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,628 |
753 |
$155K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,760 |
1,560 |
$71K |
| D1120 |
Prophylaxis - child |
2,196 |
1,968 |
$54K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
363 |
243 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,467 |
1,303 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
458 |
227 |
$32K |
| D1206 |
Topical application of fluoride varnish |
2,126 |
1,905 |
$31K |
| D0330 |
Panoramic radiographic image |
662 |
585 |
$30K |
| D1110 |
Prophylaxis - adult |
716 |
640 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
361 |
207 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,326 |
1,183 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,185 |
828 |
$17K |
| D0272 |
Bitewings - two radiographic images |
890 |
825 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
360 |
301 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
391 |
352 |
$13K |
| D1351 |
Sealant - per tooth |
468 |
160 |
$11K |
| D0274 |
Bitewings - four radiographic images |
477 |
422 |
$11K |
| D2394 |
|
65 |
37 |
$9K |
| D0240 |
|
390 |
263 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
561 |
502 |
$8K |
| D2332 |
|
19 |
12 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
12 |
$932.80 |
| D3120 |
|
61 |
34 |
$0.00 |