| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
6,047 |
3,195 |
$595K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,700 |
1,425 |
$352K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,152 |
1,138 |
$219K |
| D1120 |
Prophylaxis - child |
4,336 |
4,267 |
$167K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,920 |
3,854 |
$164K |
| D1110 |
Prophylaxis - adult |
3,001 |
2,939 |
$154K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,807 |
5,712 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
3,964 |
3,896 |
$105K |
| D0210 |
Intraoral - complete series of radiographic images |
1,901 |
1,862 |
$102K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
710 |
119 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
6,752 |
6,618 |
$87K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
527 |
318 |
$83K |
| D8660 |
|
574 |
574 |
$83K |
| D0274 |
Bitewings - four radiographic images |
2,236 |
2,204 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,030 |
3,942 |
$51K |
| D2740 |
Crown - porcelain/ceramic |
59 |
41 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,892 |
1,866 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
847 |
828 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,408 |
1,386 |
$31K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
27 |
25 |
$30K |
| D0330 |
Panoramic radiographic image |
451 |
434 |
$23K |
| D1351 |
Sealant - per tooth |
627 |
219 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
560 |
559 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
482 |
434 |
$16K |
| D1352 |
|
115 |
34 |
$11K |
| D1354 |
|
204 |
58 |
$11K |
| D2934 |
|
49 |
13 |
$9K |
| D2950 |
|
61 |
51 |
$8K |
| D4341 |
|
29 |
12 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
84 |
26 |
$7K |
| D0160 |
|
54 |
46 |
$4K |
| D9243 |
|
12 |
12 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
13 |
13 |
$2K |
| D9239 |
|
12 |
12 |
$1K |
| D9310 |
|
28 |
28 |
$1K |
| D0460 |
|
39 |
39 |
$1K |
| D4346 |
|
14 |
14 |
$657.30 |
| D0270 |
|
24 |
24 |
$357.33 |