| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,124 |
1,139 |
$150K |
| D9248 |
|
1,768 |
1,599 |
$137K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,300 |
959 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,711 |
868 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,505 |
3,408 |
$81K |
| D1120 |
Prophylaxis - child |
2,356 |
2,280 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,608 |
3,505 |
$70K |
| D1110 |
Prophylaxis - adult |
1,472 |
1,436 |
$60K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
749 |
203 |
$59K |
| D2330 |
|
1,089 |
354 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,098 |
963 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
899 |
872 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
173 |
58 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,038 |
1,005 |
$17K |
| D0274 |
Bitewings - four radiographic images |
624 |
606 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,009 |
926 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
406 |
376 |
$8K |
| D0330 |
Panoramic radiographic image |
167 |
163 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
806 |
299 |
$6K |
| D1351 |
Sealant - per tooth |
181 |
75 |
$6K |
| D2332 |
|
33 |
13 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
33 |
31 |
$2K |
| D9420 |
|
447 |
424 |
$25.00 |