| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,332 |
785 |
$229K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,615 |
647 |
$124K |
| D1351 |
Sealant - per tooth |
1,692 |
368 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,223 |
1,212 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,868 |
1,255 |
$32K |
| D1120 |
Prophylaxis - child |
880 |
869 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
143 |
69 |
$19K |
| D0274 |
Bitewings - four radiographic images |
546 |
538 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,237 |
1,222 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
119 |
119 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
167 |
120 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,275 |
1,261 |
$16K |
| D1110 |
Prophylaxis - adult |
288 |
286 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
315 |
312 |
$8K |
| D2332 |
|
42 |
25 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
70 |
37 |
$5K |
| D2330 |
|
65 |
45 |
$5K |
| D0272 |
Bitewings - two radiographic images |
208 |
208 |
$5K |
| D7111 |
|
37 |
26 |
$378.51 |
| D0602 |
|
101 |
101 |
$0.00 |
| D0603 |
|
1,305 |
1,280 |
$0.00 |