| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,178 |
947 |
$4K |
| D1120 |
Prophylaxis - child |
4,818 |
4,736 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,177 |
2,118 |
$3K |
| D1110 |
Prophylaxis - adult |
1,795 |
1,752 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,628 |
910 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,225 |
3,150 |
$1K |
| D0274 |
Bitewings - four radiographic images |
902 |
883 |
$1K |
| D1206 |
Topical application of fluoride varnish |
3,227 |
3,188 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
640 |
340 |
$959.75 |
| D1351 |
Sealant - per tooth |
1,267 |
348 |
$838.90 |
| D0272 |
Bitewings - two radiographic images |
2,123 |
2,084 |
$738.13 |
| D9248 |
|
486 |
466 |
$548.04 |
| D0120 |
Periodic oral evaluation - established patient |
3,530 |
3,495 |
$538.88 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
955 |
928 |
$495.50 |
| D0145 |
Oral evaluation for a patient under three years of age |
597 |
592 |
$425.48 |
| D0330 |
Panoramic radiographic image |
219 |
216 |
$417.06 |
| D0140 |
Limited oral evaluation - problem focused |
545 |
525 |
$390.33 |
| D0220 |
Intraoral - periapical first radiographic image |
1,708 |
1,624 |
$366.03 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,085 |
729 |
$190.74 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
267 |
114 |
$0.00 |
| D1354 |
|
26 |
12 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
81 |
27 |
$0.00 |
| D0603 |
|
370 |
364 |
$0.00 |
| D0602 |
|
62 |
61 |
$0.00 |
| D0601 |
|
53 |
53 |
$0.00 |