| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,893 |
2,061 |
$483K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,065 |
793 |
$440K |
| D0120 |
Periodic oral evaluation - established patient |
12,254 |
12,142 |
$346K |
| D1351 |
Sealant - per tooth |
13,110 |
2,904 |
$342K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,192 |
13,636 |
$317K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,230 |
2,210 |
$307K |
| D1120 |
Prophylaxis - child |
8,405 |
8,305 |
$298K |
| D1110 |
Prophylaxis - adult |
4,607 |
4,558 |
$244K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,192 |
14,034 |
$203K |
| D0274 |
Bitewings - four radiographic images |
6,511 |
6,431 |
$195K |
| D0220 |
Intraoral - periapical first radiographic image |
14,362 |
14,185 |
$165K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,795 |
579 |
$146K |
| D9248 |
|
839 |
822 |
$97K |
| D0272 |
Bitewings - two radiographic images |
1,775 |
1,762 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
509 |
273 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,133 |
1,103 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
494 |
492 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
487 |
236 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
490 |
478 |
$13K |
| D0330 |
Panoramic radiographic image |
1,514 |
1,496 |
$11K |
| D0160 |
|
637 |
625 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
75 |
$1K |
| D0603 |
|
12,537 |
12,407 |
$9.00 |
| D0602 |
|
2,846 |
2,821 |
$0.01 |
| D0601 |
|
1,039 |
1,029 |
$0.00 |