| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,282 |
3,563 |
$564K |
| D1120 |
Prophylaxis - child |
13,520 |
13,516 |
$443K |
| D0120 |
Periodic oral evaluation - established patient |
13,920 |
13,914 |
$312K |
| D1351 |
Sealant - per tooth |
3,761 |
2,131 |
$202K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,111 |
16,109 |
$183K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,883 |
2,340 |
$135K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,340 |
1,016 |
$111K |
| D1110 |
Prophylaxis - adult |
2,552 |
2,551 |
$111K |
| D0272 |
Bitewings - two radiographic images |
7,732 |
7,731 |
$103K |
| D0220 |
Intraoral - periapical first radiographic image |
9,038 |
9,010 |
$96K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
776 |
637 |
$82K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
791 |
652 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,205 |
2,205 |
$50K |
| D0330 |
Panoramic radiographic image |
1,498 |
1,498 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,659 |
6,655 |
$37K |
| D2330 |
|
125 |
58 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
430 |
428 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
119 |
111 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$342.25 |
| D9999 |
Unspecified adjunctive procedure, by report |
18 |
18 |
$0.00 |
| D1999 |
|
52 |
50 |
$0.00 |