| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,527 |
1,378 |
$334K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,593 |
1,558 |
$216K |
| D1351 |
Sealant - per tooth |
5,406 |
1,343 |
$139K |
| D1120 |
Prophylaxis - child |
3,893 |
3,792 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
3,228 |
3,149 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,044 |
3,472 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,920 |
4,801 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
1,066 |
1,036 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,529 |
2,428 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
623 |
352 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,866 |
3,764 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,158 |
1,127 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
220 |
39 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,295 |
1,269 |
$28K |
| D1110 |
Prophylaxis - adult |
300 |
291 |
$15K |
| D0274 |
Bitewings - four radiographic images |
402 |
395 |
$12K |
| D9248 |
|
75 |
71 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
49 |
13 |
$4K |
| D0160 |
|
231 |
222 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$2K |
| D1330 |
|
159 |
152 |
$1K |
| D0603 |
|
7,864 |
7,687 |
$0.00 |