| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,428 |
980 |
$216K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,457 |
992 |
$164K |
| D1351 |
Sealant - per tooth |
6,335 |
1,392 |
$163K |
| D1120 |
Prophylaxis - child |
3,438 |
3,300 |
$111K |
| D0145 |
Oral evaluation for a patient under three years of age |
788 |
765 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
3,651 |
3,497 |
$94K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
623 |
242 |
$82K |
| D0272 |
Bitewings - two radiographic images |
2,432 |
2,323 |
$49K |
| D1110 |
Prophylaxis - adult |
942 |
894 |
$44K |
| D9248 |
|
403 |
360 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,033 |
2,918 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
516 |
499 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,391 |
1,274 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
828 |
792 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,274 |
1,204 |
$16K |
| D0274 |
Bitewings - four radiographic images |
472 |
452 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,012 |
934 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
765 |
519 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
28 |
$3K |
| D0330 |
Panoramic radiographic image |
49 |
48 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
14 |
$2K |
| D1330 |
|
34 |
33 |
$208.25 |
| D0603 |
|
5,018 |
4,827 |
$0.00 |
| D0602 |
|
375 |
359 |
$0.00 |