| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,219 |
455 |
$119K |
| D0145 |
Oral evaluation for a patient under three years of age |
343 |
332 |
$47K |
| D1351 |
Sealant - per tooth |
1,654 |
362 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
579 |
284 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
741 |
677 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
146 |
86 |
$22K |
| D1120 |
Prophylaxis - child |
485 |
457 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
633 |
554 |
$17K |
| D0330 |
Panoramic radiographic image |
321 |
286 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
925 |
444 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
619 |
576 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
515 |
483 |
$6K |
| D2330 |
|
73 |
41 |
$5K |
| D1110 |
Prophylaxis - adult |
112 |
99 |
$5K |
| D0272 |
Bitewings - two radiographic images |
172 |
167 |
$4K |
| D0274 |
Bitewings - four radiographic images |
124 |
104 |
$3K |
| D2335 |
|
17 |
12 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$918.32 |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$750.10 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
27 |
$525.84 |
| D0603 |
|
1,138 |
1,058 |
$0.00 |