| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,616 |
1,037 |
$196K |
| D1120 |
Prophylaxis - child |
3,374 |
3,372 |
$141K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
597 |
472 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
2,863 |
2,861 |
$94K |
| D1206 |
Topical application of fluoride varnish |
3,337 |
3,335 |
$93K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
426 |
339 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
556 |
386 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
526 |
377 |
$48K |
| D1351 |
Sealant - per tooth |
1,189 |
422 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,486 |
1,485 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
112 |
$18K |
| D9310 |
|
194 |
194 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
762 |
760 |
$14K |
| D0330 |
Panoramic radiographic image |
190 |
190 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
570 |
369 |
$8K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$4K |
| D0191 |
|
100 |
100 |
$2K |
| D2330 |
|
21 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$803.71 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,700 |
1,622 |
$0.00 |