| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,216 |
646 |
$227K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,345 |
381 |
$106K |
| D0210 |
Intraoral - complete series of radiographic images |
872 |
870 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
875 |
872 |
$29K |
| D1120 |
Prophylaxis - child |
616 |
613 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
136 |
44 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
647 |
645 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,039 |
1,037 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
133 |
42 |
$11K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$7K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$280.56 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$150.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$138.12 |
| D0603 |
|
1,230 |
1,197 |
$0.00 |