| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
6,806 |
3,772 |
$555K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,809 |
3,063 |
$339K |
| D1120 |
Prophylaxis - child |
10,186 |
9,834 |
$333K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,372 |
2,791 |
$318K |
| D0120 |
Periodic oral evaluation - established patient |
10,758 |
10,376 |
$252K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,286 |
11,842 |
$246K |
| D1110 |
Prophylaxis - adult |
3,744 |
3,602 |
$155K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,458 |
1,439 |
$147K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,225 |
617 |
$128K |
| D9248 |
|
1,411 |
1,285 |
$109K |
| D0274 |
Bitewings - four radiographic images |
3,448 |
3,328 |
$90K |
| D0330 |
Panoramic radiographic image |
2,330 |
2,245 |
$89K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,068 |
590 |
$80K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,581 |
2,411 |
$71K |
| D0272 |
Bitewings - two radiographic images |
3,798 |
3,648 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
4,302 |
4,041 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,351 |
1,283 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,354 |
1,315 |
$27K |
| D9110 |
|
576 |
550 |
$26K |
| D1351 |
Sealant - per tooth |
603 |
288 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
461 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
728 |
554 |
$6K |
| D1510 |
|
42 |
37 |
$6K |
| D2394 |
|
19 |
12 |
$2K |
| D2330 |
|
18 |
13 |
$824.72 |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$496.03 |
| D3120 |
|
81 |
56 |
$0.00 |