| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,931 |
2,215 |
$467K |
| D1120 |
Prophylaxis - child |
9,645 |
9,641 |
$379K |
| D0120 |
Periodic oral evaluation - established patient |
9,406 |
9,402 |
$296K |
| D1206 |
Topical application of fluoride varnish |
10,130 |
10,126 |
$265K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,119 |
626 |
$205K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,233 |
1,316 |
$180K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,847 |
1,285 |
$166K |
| D0272 |
Bitewings - two radiographic images |
5,335 |
5,334 |
$128K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
727 |
469 |
$87K |
| D1351 |
Sealant - per tooth |
2,640 |
846 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
805 |
805 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
799 |
788 |
$45K |
| D9248 |
|
845 |
785 |
$43K |
| D9310 |
|
608 |
608 |
$41K |
| D1110 |
Prophylaxis - adult |
866 |
865 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
1,897 |
1,880 |
$33K |
| D0240 |
|
1,520 |
821 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,016 |
513 |
$12K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$8K |
| D2332 |
|
57 |
36 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$2K |
| D2330 |
|
21 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,390 |
3,133 |
$0.00 |