| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,019 |
390 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
511 |
293 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
557 |
544 |
$38K |
| D1351 |
Sealant - per tooth |
1,312 |
298 |
$34K |
| D0145 |
Oral evaluation for a patient under three years of age |
216 |
215 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
604 |
587 |
$21K |
| D1120 |
Prophylaxis - child |
521 |
513 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
547 |
513 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
669 |
657 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
57 |
29 |
$8K |
| D1110 |
Prophylaxis - adult |
122 |
119 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
117 |
117 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
246 |
110 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
130 |
$2K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$958.58 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$415.32 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$244.14 |
| D1330 |
|
15 |
12 |
$147.50 |
| D0603 |
|
998 |
969 |
$0.00 |