| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
11,321 |
6,411 |
$746K |
| D0120 |
Periodic oral evaluation - established patient |
10,589 |
10,520 |
$739K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,985 |
10,929 |
$720K |
| D1110 |
Prophylaxis - adult |
6,934 |
6,891 |
$605K |
| D1120 |
Prophylaxis - child |
12,445 |
12,363 |
$553K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,359 |
788 |
$517K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
9,520 |
5,103 |
$506K |
| D0210 |
Intraoral - complete series of radiographic images |
8,123 |
8,083 |
$382K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,050 |
1,598 |
$358K |
| D1206 |
Topical application of fluoride varnish |
19,707 |
19,580 |
$315K |
| D2740 |
Crown - porcelain/ceramic |
651 |
555 |
$304K |
| D0350 |
|
25,451 |
9,542 |
$248K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,301 |
653 |
$227K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,869 |
2,102 |
$223K |
| D1351 |
Sealant - per tooth |
5,357 |
1,298 |
$163K |
| D0274 |
Bitewings - four radiographic images |
7,466 |
7,411 |
$156K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,659 |
1,028 |
$151K |
| D4341 |
|
1,841 |
514 |
$128K |
| D9430 |
|
3,778 |
3,719 |
$121K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,573 |
12,822 |
$113K |
| D1310 |
|
1,907 |
1,891 |
$86K |
| D2330 |
|
809 |
489 |
$61K |
| D0330 |
Panoramic radiographic image |
1,570 |
1,559 |
$45K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
106 |
78 |
$37K |
| D0272 |
Bitewings - two radiographic images |
3,184 |
3,165 |
$36K |
| D9993 |
|
582 |
582 |
$36K |
| D4910 |
|
415 |
413 |
$31K |
| D9248 |
|
712 |
711 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,112 |
1,095 |
$13K |
| D0601 |
|
671 |
664 |
$10K |
| D9222 |
|
79 |
79 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
64 |
64 |
$5K |
| D2331 |
|
60 |
38 |
$5K |
| D0603 |
|
206 |
204 |
$3K |
| D2332 |
|
35 |
17 |
$3K |
| D2394 |
|
20 |
12 |
$2K |
| D2954 |
|
16 |
15 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
120 |
113 |
$2K |
| D7111 |
|
22 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$720.00 |
| D0270 |
|
86 |
85 |
$395.00 |
| D0602 |
|
12 |
12 |
$180.00 |
| D1999 |
|
20 |
15 |
$15.00 |