| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,330 |
1,775 |
$529K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,785 |
1,073 |
$138K |
| D0210 |
Intraoral - complete series of radiographic images |
1,975 |
1,958 |
$130K |
| D1351 |
Sealant - per tooth |
3,431 |
855 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,299 |
2,280 |
$73K |
| D1120 |
Prophylaxis - child |
1,569 |
1,557 |
$56K |
| D1110 |
Prophylaxis - adult |
750 |
741 |
$40K |
| D0145 |
Oral evaluation for a patient under three years of age |
266 |
264 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,304 |
2,285 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,701 |
396 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
118 |
93 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
28 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
408 |
403 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
161 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
134 |
132 |
$3K |
| D2331 |
|
32 |
24 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$380.71 |
| D0603 |
|
2,771 |
2,618 |
$0.00 |