| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,088 |
2,474 |
$572K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,975 |
1,688 |
$291K |
| D1351 |
Sealant - per tooth |
7,479 |
2,140 |
$191K |
| D0120 |
Periodic oral evaluation - established patient |
6,840 |
6,537 |
$186K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,030 |
1,005 |
$141K |
| D1110 |
Prophylaxis - adult |
2,657 |
2,569 |
$137K |
| D1120 |
Prophylaxis - child |
3,929 |
3,764 |
$134K |
| D0274 |
Bitewings - four radiographic images |
4,093 |
3,929 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,064 |
6,747 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
7,444 |
7,089 |
$88K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,016 |
6,648 |
$76K |
| D2330 |
|
724 |
512 |
$51K |
| D0272 |
Bitewings - two radiographic images |
2,165 |
2,102 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
162 |
72 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
435 |
405 |
$11K |
| D2332 |
|
73 |
61 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$565.12 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$507.06 |
| D0603 |
|
3,446 |
3,350 |
$0.00 |
| D0602 |
|
3,159 |
3,045 |
$0.00 |
| D0601 |
|
855 |
831 |
$0.00 |