| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,931 |
777 |
$54K |
| D1120 |
Prophylaxis - child |
1,964 |
1,913 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
974 |
454 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
821 |
302 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
594 |
246 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
801 |
777 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,194 |
2,136 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,834 |
1,783 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,872 |
1,830 |
$12K |
| D1351 |
Sealant - per tooth |
908 |
263 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,483 |
1,354 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
303 |
186 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,521 |
1,091 |
$5K |
| D1110 |
Prophylaxis - adult |
329 |
316 |
$4K |
| D9248 |
|
298 |
244 |
$4K |
| D2332 |
|
63 |
28 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
561 |
475 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
149 |
62 |
$2K |
| D0274 |
Bitewings - four radiographic images |
282 |
265 |
$2K |
| D1206 |
Topical application of fluoride varnish |
230 |
221 |
$813.35 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$309.96 |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
36 |
$0.00 |