| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,140 |
2,202 |
$398K |
| D1351 |
Sealant - per tooth |
11,466 |
2,943 |
$307K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,678 |
1,673 |
$234K |
| D1120 |
Prophylaxis - child |
6,046 |
5,982 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
6,773 |
6,690 |
$191K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,762 |
7,545 |
$183K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,111 |
275 |
$156K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,571 |
8,488 |
$122K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,833 |
3,757 |
$100K |
| D1110 |
Prophylaxis - adult |
1,870 |
1,851 |
$99K |
| D0220 |
Intraoral - periapical first radiographic image |
8,133 |
8,014 |
$98K |
| D0210 |
Intraoral - complete series of radiographic images |
988 |
981 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,827 |
1,801 |
$61K |
| D0272 |
Bitewings - two radiographic images |
2,236 |
2,204 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
587 |
363 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,294 |
1,284 |
$44K |
| D9248 |
|
197 |
191 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
242 |
67 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
82 |
$11K |
| D2934 |
|
46 |
12 |
$5K |
| D0160 |
|
333 |
328 |
$5K |
| D1330 |
|
223 |
219 |
$2K |
| D0350 |
|
92 |
89 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$694.86 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$176.40 |
| D0603 |
|
11,565 |
11,467 |
$0.00 |