| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,348 |
724 |
$237K |
| D1120 |
Prophylaxis - child |
3,702 |
3,688 |
$203K |
| D0120 |
Periodic oral evaluation - established patient |
3,748 |
3,736 |
$196K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,597 |
3,574 |
$110K |
| D0277 |
|
1,574 |
1,570 |
$109K |
| D1351 |
Sealant - per tooth |
2,276 |
615 |
$100K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,338 |
1,247 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
141 |
$29K |
| D0602 |
|
2,087 |
2,081 |
$13K |
| D0603 |
|
1,989 |
1,979 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
48 |
15 |
$10K |
| D0330 |
Panoramic radiographic image |
108 |
108 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
28 |
$8K |
| D0240 |
|
221 |
123 |
$7K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
32 |
14 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$5K |
| D0251 |
|
55 |
55 |
$3K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$2K |
| D1999 |
|
1,047 |
1,006 |
$2K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$759.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$248.47 |
| D1310 |
|
130 |
130 |
$52.50 |
| D1330 |
|
130 |
130 |
$0.00 |