| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,014 |
1,298 |
$169K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,721 |
750 |
$121K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,001 |
2,910 |
$96K |
| D1120 |
Prophylaxis - child |
5,240 |
5,125 |
$90K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,715 |
866 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
3,564 |
3,500 |
$65K |
| D1206 |
Topical application of fluoride varnish |
5,839 |
5,707 |
$65K |
| D1351 |
Sealant - per tooth |
3,579 |
999 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,695 |
2,433 |
$49K |
| D0272 |
Bitewings - two radiographic images |
2,952 |
2,905 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
868 |
542 |
$34K |
| D0330 |
Panoramic radiographic image |
1,190 |
1,162 |
$31K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
563 |
349 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,055 |
1,511 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,632 |
2,557 |
$20K |
| D3120 |
|
760 |
416 |
$17K |
| D1110 |
Prophylaxis - adult |
687 |
673 |
$16K |
| D0274 |
Bitewings - four radiographic images |
937 |
911 |
$15K |
| D2331 |
|
258 |
163 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
621 |
591 |
$10K |
| D2332 |
|
41 |
27 |
$2K |
| D2330 |
|
23 |
13 |
$929.00 |