| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
10,166 |
2,529 |
$457K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,590 |
3,013 |
$355K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,537 |
610 |
$151K |
| D1120 |
Prophylaxis - child |
7,425 |
7,277 |
$116K |
| D1206 |
Topical application of fluoride varnish |
11,742 |
11,510 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
9,061 |
8,912 |
$101K |
| D1110 |
Prophylaxis - adult |
4,092 |
4,003 |
$99K |
| D0274 |
Bitewings - four radiographic images |
6,341 |
6,197 |
$93K |
| D0220 |
Intraoral - periapical first radiographic image |
14,289 |
13,785 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,307 |
11,734 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,601 |
2,527 |
$61K |
| D0330 |
Panoramic radiographic image |
1,942 |
1,822 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,841 |
983 |
$47K |
| D0272 |
Bitewings - two radiographic images |
5,081 |
4,974 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
2,650 |
2,436 |
$35K |
| D1351 |
Sealant - per tooth |
2,441 |
824 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
415 |
186 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,844 |
1,577 |
$15K |
| D2394 |
|
64 |
39 |
$8K |
| D2335 |
|
47 |
25 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
78 |
51 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
28 |
$2K |
| D0270 |
|
737 |
683 |
$2K |
| D3120 |
|
52 |
21 |
$1K |
| D1352 |
|
64 |
44 |
$656.20 |
| D0601 |
|
917 |
853 |
$0.00 |
| D1310 |
|
16 |
16 |
$0.00 |
| D0602 |
|
205 |
202 |
$0.00 |
| D0603 |
|
15 |
15 |
$0.00 |
| D1330 |
|
16 |
16 |
$0.00 |