| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,646 |
2,466 |
$353K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,580 |
1,783 |
$346K |
| D1351 |
Sealant - per tooth |
11,449 |
2,903 |
$298K |
| D0120 |
Periodic oral evaluation - established patient |
8,009 |
7,911 |
$222K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,298 |
7,621 |
$200K |
| D1120 |
Prophylaxis - child |
5,330 |
5,268 |
$186K |
| D1110 |
Prophylaxis - adult |
3,006 |
2,964 |
$157K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,025 |
1,012 |
$138K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,003 |
8,890 |
$126K |
| D0274 |
Bitewings - four radiographic images |
3,153 |
3,109 |
$103K |
| D0220 |
Intraoral - periapical first radiographic image |
8,053 |
7,943 |
$97K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,691 |
3,598 |
$96K |
| D0210 |
Intraoral - complete series of radiographic images |
918 |
914 |
$57K |
| D7240 |
Removal of impacted tooth - completely bony |
172 |
53 |
$49K |
| D0272 |
Bitewings - two radiographic images |
1,780 |
1,751 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
144 |
27 |
$21K |
| D9248 |
|
166 |
166 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
458 |
455 |
$16K |
| D0160 |
|
292 |
290 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
12 |
$3K |
| D1330 |
|
91 |
91 |
$1K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$487.86 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$225.36 |
| D0603 |
|
11,139 |
11,000 |
$0.01 |