| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,149 |
685 |
$146K |
| D1120 |
Prophylaxis - child |
2,791 |
2,786 |
$112K |
| D1206 |
Topical application of fluoride varnish |
3,537 |
3,528 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,537 |
1,534 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
425 |
193 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
540 |
341 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,746 |
1,742 |
$48K |
| D1110 |
Prophylaxis - adult |
765 |
763 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
361 |
189 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,112 |
1,035 |
$35K |
| D1351 |
Sealant - per tooth |
849 |
280 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,586 |
1,583 |
$34K |
| D0330 |
Panoramic radiographic image |
499 |
498 |
$26K |
| D0274 |
Bitewings - four radiographic images |
450 |
449 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
853 |
839 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
243 |
239 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
241 |
241 |
$8K |
| D0240 |
|
193 |
191 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
229 |
228 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
24 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
60 |
$362.10 |