| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,919 |
2,650 |
$460K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,137 |
1,629 |
$403K |
| D1120 |
Prophylaxis - child |
10,084 |
10,084 |
$386K |
| D0120 |
Periodic oral evaluation - established patient |
10,358 |
10,358 |
$311K |
| D1206 |
Topical application of fluoride varnish |
10,682 |
10,682 |
$270K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,702 |
1,660 |
$223K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,699 |
1,348 |
$154K |
| D1351 |
Sealant - per tooth |
4,306 |
1,418 |
$125K |
| D0272 |
Bitewings - two radiographic images |
4,868 |
4,868 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,839 |
1,839 |
$91K |
| D1110 |
Prophylaxis - adult |
1,391 |
1,391 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
3,341 |
3,319 |
$59K |
| D0330 |
Panoramic radiographic image |
570 |
570 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
276 |
226 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,488 |
1,777 |
$32K |
| D0274 |
Bitewings - four radiographic images |
575 |
575 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
228 |
227 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
168 |
168 |
$7K |
| D2332 |
|
18 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
494 |
474 |
$0.00 |
| D1999 |
|
2,327 |
2,207 |
$0.00 |