| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,415 |
796 |
$154K |
| D1120 |
Prophylaxis - child |
6,990 |
5,155 |
$151K |
| D1206 |
Topical application of fluoride varnish |
4,060 |
3,858 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,128 |
2,081 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
4,400 |
2,652 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
849 |
493 |
$66K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,725 |
1,619 |
$57K |
| D1351 |
Sealant - per tooth |
1,944 |
303 |
$53K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
399 |
230 |
$52K |
| D0330 |
Panoramic radiographic image |
1,160 |
1,112 |
$48K |
| D0272 |
Bitewings - two radiographic images |
3,040 |
2,276 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,519 |
1,284 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
364 |
254 |
$31K |
| D9248 |
|
483 |
468 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
292 |
283 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,276 |
1,191 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
335 |
321 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
812 |
770 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
52 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
157 |
153 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
844 |
308 |
$4K |
| D0603 |
|
2,028 |
1,423 |
$0.00 |