| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,550 |
1,158 |
$345K |
| D0145 |
Oral evaluation for a patient under three years of age |
757 |
739 |
$104K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
631 |
171 |
$91K |
| D0210 |
Intraoral - complete series of radiographic images |
1,317 |
1,276 |
$87K |
| D1351 |
Sealant - per tooth |
2,592 |
677 |
$69K |
| D1120 |
Prophylaxis - child |
1,631 |
1,597 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,530 |
1,487 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
652 |
318 |
$47K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,770 |
1,681 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,315 |
2,243 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
898 |
878 |
$25K |
| D1110 |
Prophylaxis - adult |
414 |
399 |
$22K |
| D9248 |
|
142 |
139 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
152 |
76 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,407 |
967 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,102 |
1,074 |
$13K |
| D0272 |
Bitewings - two radiographic images |
494 |
481 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
90 |
39 |
$8K |
| D1330 |
|
319 |
308 |
$4K |
| D0160 |
|
206 |
201 |
$3K |
| D0274 |
Bitewings - four radiographic images |
72 |
69 |
$2K |
| D0350 |
|
80 |
73 |
$843.64 |
| D0603 |
|
3,850 |
3,743 |
$0.00 |