| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,012 |
488 |
$98K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
589 |
276 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
2,902 |
2,881 |
$79K |
| D1120 |
Prophylaxis - child |
1,901 |
1,880 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
801 |
430 |
$58K |
| D1351 |
Sealant - per tooth |
2,174 |
626 |
$57K |
| D1110 |
Prophylaxis - adult |
983 |
979 |
$50K |
| D0145 |
Oral evaluation for a patient under three years of age |
350 |
347 |
$48K |
| D9248 |
|
386 |
379 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,956 |
2,931 |
$41K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
424 |
208 |
$34K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
434 |
211 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,445 |
1,418 |
$32K |
| D0274 |
Bitewings - four radiographic images |
884 |
880 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,104 |
2,055 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
847 |
805 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,980 |
1,827 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
263 |
165 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
48 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
118 |
$4K |
| D2140 |
|
42 |
30 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$225.36 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$219.63 |
| D0603 |
|
2,440 |
2,419 |
$0.00 |
| D0601 |
|
372 |
370 |
$0.00 |
| D0602 |
|
482 |
482 |
$0.00 |