| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,161 |
1,212 |
$158K |
| D1120 |
Prophylaxis - child |
4,683 |
4,681 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
3,697 |
3,696 |
$100K |
| D1206 |
Topical application of fluoride varnish |
2,039 |
2,037 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
580 |
410 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,404 |
2,404 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
165 |
122 |
$22K |
| D0603 |
|
1,446 |
1,446 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
279 |
184 |
$14K |
| D0240 |
|
1,076 |
1,067 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,002 |
1,001 |
$10K |
| D1351 |
Sealant - per tooth |
140 |
43 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
24 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
92 |
92 |
$3K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
205 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
44 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$630.00 |
| D2330 |
|
15 |
13 |
$570.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
64 |
$368.00 |
| D1330 |
|
577 |
561 |
$0.00 |