| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,250 |
1,640 |
$220K |
| D1120 |
Prophylaxis - child |
5,569 |
5,569 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
5,307 |
5,307 |
$126K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,048 |
549 |
$125K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,076 |
3,837 |
$124K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,894 |
6,894 |
$113K |
| D1110 |
Prophylaxis - adult |
2,107 |
2,107 |
$98K |
| D7140 |
Extraction, erupted tooth or exposed root |
946 |
580 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,008 |
2,008 |
$81K |
| D0240 |
|
3,201 |
1,755 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,686 |
2,686 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
382 |
331 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
960 |
952 |
$36K |
| D0145 |
Oral evaluation for a patient under three years of age |
698 |
698 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,107 |
1,107 |
$30K |
| D7111 |
|
288 |
209 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
200 |
124 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
916 |
907 |
$12K |
| D0330 |
Panoramic radiographic image |
216 |
216 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
108 |
$10K |
| D1351 |
Sealant - per tooth |
291 |
116 |
$8K |
| D9420 |
|
89 |
89 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
599 |
251 |
$7K |
| D2331 |
|
64 |
41 |
$5K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$458.40 |