| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23,372 |
6,608 |
$2.25M |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14,732 |
3,768 |
$1.09M |
| D0145 |
Oral evaluation for a patient under three years of age |
4,146 |
4,037 |
$560K |
| D0120 |
Periodic oral evaluation - established patient |
20,489 |
19,919 |
$556K |
| D1120 |
Prophylaxis - child |
14,261 |
13,839 |
$489K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,482 |
889 |
$462K |
| D1110 |
Prophylaxis - adult |
7,421 |
7,219 |
$384K |
| D1351 |
Sealant - per tooth |
13,192 |
3,472 |
$333K |
| D0274 |
Bitewings - four radiographic images |
9,722 |
9,475 |
$314K |
| D1208 |
Topical application of fluoride, excluding varnish |
22,095 |
21,470 |
$306K |
| D7240 |
Removal of impacted tooth - completely bony |
1,027 |
295 |
$268K |
| D0220 |
Intraoral - periapical first radiographic image |
21,423 |
20,592 |
$249K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,379 |
19,366 |
$247K |
| D0272 |
Bitewings - two radiographic images |
9,512 |
9,226 |
$189K |
| D9248 |
|
1,015 |
938 |
$108K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,856 |
1,774 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,350 |
1,277 |
$42K |
| D0330 |
Panoramic radiographic image |
1,191 |
1,137 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
274 |
274 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
977 |
932 |
$17K |
| D2330 |
|
112 |
65 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
101 |
48 |
$7K |
| D9243 |
|
187 |
84 |
$6K |
| D9239 |
|
88 |
87 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
54 |
21 |
$1K |
| D9610 |
|
71 |
68 |
$1K |
| D7111 |
|
79 |
58 |
$857.58 |
| D9222 |
|
19 |
19 |
$826.03 |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$543.90 |
| D0160 |
|
39 |
34 |
$491.86 |
| D9310 |
|
35 |
35 |
$320.76 |
| D0270 |
|
41 |
39 |
$186.20 |
| D0603 |
|
26,505 |
26,003 |
$0.00 |