| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,490 |
654 |
$242K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,424 |
386 |
$110K |
| D0210 |
Intraoral - complete series of radiographic images |
827 |
811 |
$53K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
268 |
80 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
832 |
814 |
$26K |
| D1120 |
Prophylaxis - child |
544 |
520 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
655 |
622 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
181 |
51 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
882 |
849 |
$12K |
| D1110 |
Prophylaxis - adult |
209 |
202 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$4K |
| D9248 |
|
13 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
12 |
$346.20 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$150.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$138.12 |
| D0603 |
|
1,178 |
1,034 |
$0.00 |