| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,431 |
947 |
$211K |
| D0145 |
Oral evaluation for a patient under three years of age |
866 |
832 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,721 |
3,674 |
$103K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,479 |
640 |
$102K |
| D1120 |
Prophylaxis - child |
2,781 |
2,735 |
$97K |
| D1110 |
Prophylaxis - adult |
1,289 |
1,260 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,912 |
1,888 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,229 |
4,155 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
3,696 |
3,631 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,637 |
3,539 |
$40K |
| D1351 |
Sealant - per tooth |
1,551 |
465 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
261 |
53 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,060 |
1,034 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
677 |
659 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
419 |
389 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
98 |
27 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
111 |
101 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
12 |
$2K |
| D9248 |
|
12 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$556.54 |
| D0603 |
|
5,450 |
5,330 |
$0.00 |
| D1999 |
|
682 |
659 |
$0.00 |