| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,881 |
990 |
$419K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
778 |
546 |
$226K |
| D1110 |
Prophylaxis - adult |
2,299 |
2,058 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
655 |
362 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
3,114 |
2,631 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,858 |
1,556 |
$105K |
| D1120 |
Prophylaxis - child |
2,025 |
1,831 |
$95K |
| D0210 |
Intraoral - complete series of radiographic images |
985 |
866 |
$83K |
| D0140 |
Limited oral evaluation - problem focused |
1,410 |
1,194 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,555 |
2,301 |
$72K |
| D9920 |
|
477 |
401 |
$59K |
| D0350 |
|
1,381 |
1,268 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,220 |
1,089 |
$54K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
240 |
119 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,431 |
1,243 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,012 |
903 |
$26K |
| D1351 |
Sealant - per tooth |
607 |
134 |
$25K |
| D0330 |
Panoramic radiographic image |
277 |
255 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
55 |
$17K |
| D4341 |
|
76 |
28 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,133 |
813 |
$15K |
| D0272 |
Bitewings - two radiographic images |
377 |
342 |
$12K |
| D2394 |
|
46 |
30 |
$11K |
| D4355 |
|
60 |
50 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
14 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
78 |
62 |
$4K |
| D0240 |
|
108 |
55 |
$2K |
| D0180 |
|
15 |
13 |
$639.28 |
| D0602 |
|
3,447 |
3,092 |
$0.00 |
| D0603 |
|
48 |
43 |
$0.00 |
| D1330 |
|
41 |
40 |
$0.00 |
| D0431 |
|
538 |
512 |
$0.00 |
| D9986 |
|
151 |
147 |
$0.00 |
| D9987 |
|
64 |
60 |
$0.00 |