| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
703 |
269 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
503 |
221 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
115 |
59 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
669 |
598 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,703 |
652 |
$13K |
| D1120 |
Prophylaxis - child |
490 |
424 |
$12K |
| D1351 |
Sealant - per tooth |
485 |
139 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
517 |
438 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
90 |
77 |
$9K |
| D1110 |
Prophylaxis - adult |
184 |
169 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
709 |
627 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
782 |
682 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
44 |
$5K |
| D0272 |
Bitewings - two radiographic images |
289 |
261 |
$5K |
| D0274 |
Bitewings - four radiographic images |
197 |
176 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
28 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
33 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
16 |
$317.88 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$206.58 |
| D0603 |
|
820 |
736 |
$0.00 |