| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,644 |
1,244 |
$261K |
| D0210 |
Intraoral - complete series of radiographic images |
2,970 |
2,943 |
$202K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,011 |
297 |
$144K |
| D1351 |
Sealant - per tooth |
5,274 |
1,130 |
$137K |
| D1110 |
Prophylaxis - adult |
2,334 |
2,315 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,264 |
3,223 |
$111K |
| D1120 |
Prophylaxis - child |
2,651 |
2,629 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,074 |
3,047 |
$86K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,781 |
5,732 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,028 |
571 |
$79K |
| D0274 |
Bitewings - four radiographic images |
1,938 |
1,914 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,206 |
3,308 |
$56K |
| D0145 |
Oral evaluation for a patient under three years of age |
393 |
391 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
3,501 |
3,467 |
$42K |
| D9248 |
|
349 |
340 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
359 |
141 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
418 |
392 |
$11K |
| D0272 |
Bitewings - two radiographic images |
281 |
279 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
24 |
$3K |
| D7111 |
|
67 |
40 |
$766.71 |
| D0603 |
|
5,007 |
4,964 |
$0.00 |
| D0602 |
|
1,953 |
1,939 |
$0.00 |
| D0601 |
|
122 |
120 |
$0.00 |