| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,687 |
1,098 |
$346K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,059 |
689 |
$159K |
| D0145 |
Oral evaluation for a patient under three years of age |
964 |
955 |
$133K |
| D1120 |
Prophylaxis - child |
1,804 |
1,776 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
392 |
87 |
$55K |
| D7240 |
Removal of impacted tooth - completely bony |
197 |
62 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,923 |
1,411 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,462 |
1,438 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,845 |
1,789 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
562 |
552 |
$34K |
| D1351 |
Sealant - per tooth |
1,243 |
304 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,312 |
2,276 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,641 |
1,612 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
651 |
640 |
$18K |
| D9248 |
|
102 |
101 |
$12K |
| D1110 |
Prophylaxis - adult |
72 |
71 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
13 |
$3K |
| D0160 |
|
143 |
140 |
$2K |
| D1330 |
|
156 |
153 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
57 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
65 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$415.32 |
| D0603 |
|
4,191 |
4,142 |
$0.00 |