| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,494 |
1,416 |
$345K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,584 |
844 |
$123K |
| D0210 |
Intraoral - complete series of radiographic images |
1,445 |
1,425 |
$98K |
| D0145 |
Oral evaluation for a patient under three years of age |
529 |
525 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,508 |
1,487 |
$52K |
| D1120 |
Prophylaxis - child |
1,548 |
1,535 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,711 |
1,648 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,115 |
2,095 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
650 |
647 |
$19K |
| D1110 |
Prophylaxis - adult |
312 |
308 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,349 |
658 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
85 |
48 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
736 |
730 |
$9K |
| D1351 |
Sealant - per tooth |
145 |
43 |
$4K |
| D0272 |
Bitewings - two radiographic images |
167 |
165 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
27 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
20 |
$3K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
14 |
$1K |
| D0603 |
|
3,183 |
3,157 |
$0.00 |