| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,729 |
1,136 |
$219K |
| D8670 |
Periodic orthodontic treatment visit |
622 |
609 |
$203K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,454 |
507 |
$168K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,299 |
1,082 |
$166K |
| D9920 |
|
1,854 |
1,766 |
$98K |
| D9248 |
|
1,060 |
988 |
$92K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,025 |
389 |
$72K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,187 |
571 |
$64K |
| D1120 |
Prophylaxis - child |
2,264 |
2,260 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,989 |
2,970 |
$49K |
| D9630 |
|
2,526 |
2,510 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
2,481 |
2,464 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,196 |
1,179 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
591 |
536 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
646 |
616 |
$12K |
| D1110 |
Prophylaxis - adult |
383 |
381 |
$12K |
| D8660 |
|
86 |
79 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
71 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
236 |
$6K |
| D0240 |
|
455 |
243 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
129 |
$4K |
| D9310 |
|
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
256 |
$2K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$314.40 |
| D1999 |
|
24 |
24 |
$0.00 |
| D1351 |
Sealant - per tooth |
34 |
17 |
$0.00 |
| D2390 |
|
31 |
13 |
$0.00 |