| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,949 |
3,270 |
$936K |
| D1110 |
Prophylaxis - adult |
9,671 |
9,664 |
$460K |
| D0120 |
Periodic oral evaluation - established patient |
18,478 |
18,465 |
$450K |
| D1206 |
Topical application of fluoride varnish |
19,790 |
19,781 |
$388K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,188 |
1,752 |
$335K |
| D1120 |
Prophylaxis - child |
9,346 |
9,341 |
$333K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,644 |
533 |
$212K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,274 |
795 |
$206K |
| D1351 |
Sealant - per tooth |
4,359 |
1,478 |
$163K |
| D0220 |
Intraoral - periapical first radiographic image |
11,601 |
11,557 |
$148K |
| D0274 |
Bitewings - four radiographic images |
4,571 |
4,564 |
$138K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,182 |
4,019 |
$132K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,320 |
9,312 |
$118K |
| D0330 |
Panoramic radiographic image |
2,201 |
2,200 |
$116K |
| D7240 |
Removal of impacted tooth - completely bony |
401 |
120 |
$113K |
| D0272 |
Bitewings - two radiographic images |
4,696 |
4,695 |
$99K |
| D9243 |
|
167 |
166 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
1,109 |
1,096 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
486 |
$20K |
| D9239 |
|
166 |
166 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
192 |
77 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
486 |
486 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
114 |
65 |
$11K |
| D7111 |
|
223 |
159 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
277 |
$10K |
| D2332 |
|
63 |
41 |
$10K |
| D9310 |
|
155 |
155 |
$6K |
| D2934 |
|
32 |
13 |
$5K |
| D1353 |
|
127 |
68 |
$5K |
| D3230 |
|
32 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
302 |
302 |
$4K |
| D3240 |
|
23 |
12 |
$3K |
| D0273 |
|
44 |
44 |
$1K |
| D0270 |
|
48 |
48 |
$609.12 |