| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
822 |
397 |
$61K |
| D1120 |
Prophylaxis - child |
684 |
680 |
$23K |
| D1354 |
|
2,338 |
411 |
$23K |
| D1351 |
Sealant - per tooth |
835 |
272 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
559 |
557 |
$17K |
| D1206 |
Topical application of fluoride varnish |
744 |
733 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
169 |
128 |
$15K |
| D9248 |
|
154 |
152 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
425 |
389 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
107 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
104 |
67 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
103 |
66 |
$9K |
| D0330 |
Panoramic radiographic image |
210 |
210 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
573 |
554 |
$7K |
| D1110 |
Prophylaxis - adult |
132 |
132 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
590 |
304 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
201 |
201 |
$5K |
| D0274 |
Bitewings - four radiographic images |
207 |
207 |
$4K |
| D0272 |
Bitewings - two radiographic images |
247 |
245 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
160 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
32 |
$3K |
| D1353 |
|
81 |
28 |
$2K |
| D9630 |
|
76 |
73 |
$2K |
| D2332 |
|
20 |
16 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$676.50 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$313.32 |
| D1330 |
|
20 |
20 |
$0.00 |
| D0603 |
|
13 |
13 |
$0.00 |