| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,842 |
2,269 |
$454K |
| D1120 |
Prophylaxis - child |
8,237 |
8,236 |
$327K |
| D0120 |
Periodic oral evaluation - established patient |
7,020 |
7,017 |
$225K |
| D1206 |
Topical application of fluoride varnish |
8,131 |
8,129 |
$219K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
976 |
754 |
$184K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,851 |
1,187 |
$165K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,185 |
800 |
$98K |
| D0272 |
Bitewings - two radiographic images |
3,217 |
3,217 |
$79K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
622 |
482 |
$78K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
442 |
389 |
$64K |
| D1351 |
Sealant - per tooth |
1,372 |
434 |
$43K |
| D9310 |
|
472 |
472 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,742 |
1,735 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
234 |
234 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,281 |
892 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
238 |
$14K |
| D0191 |
|
304 |
304 |
$5K |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$3K |
| D9248 |
|
42 |
42 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
46 |
46 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |
| D2330 |
|
22 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,655 |
2,421 |
$0.00 |