| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,085 |
2,201 |
$487K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,385 |
1,074 |
$451K |
| D1120 |
Prophylaxis - child |
9,817 |
9,811 |
$398K |
| D1206 |
Topical application of fluoride varnish |
10,631 |
10,626 |
$280K |
| D0120 |
Periodic oral evaluation - established patient |
8,942 |
8,940 |
$274K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,170 |
1,213 |
$184K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,560 |
1,015 |
$139K |
| D1351 |
Sealant - per tooth |
3,688 |
1,155 |
$113K |
| D0272 |
Bitewings - two radiographic images |
4,235 |
4,233 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,848 |
1,846 |
$102K |
| D0330 |
Panoramic radiographic image |
1,219 |
1,217 |
$85K |
| D1110 |
Prophylaxis - adult |
1,725 |
1,725 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
2,887 |
2,853 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
302 |
214 |
$43K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
311 |
168 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
580 |
574 |
$32K |
| D0274 |
Bitewings - four radiographic images |
725 |
725 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,516 |
1,286 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
403 |
403 |
$16K |
| D9310 |
|
48 |
48 |
$4K |
| D2332 |
|
30 |
12 |
$3K |
| D9920 |
|
45 |
38 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,195 |
2,022 |
$0.00 |
| D1999 |
|
910 |
793 |
$0.00 |