| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,690 |
1,324 |
$317K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,385 |
757 |
$225K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,923 |
497 |
$197K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,396 |
333 |
$169K |
| D0330 |
Panoramic radiographic image |
1,833 |
1,797 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,024 |
543 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,005 |
1,963 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
3,907 |
3,830 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,936 |
1,889 |
$58K |
| D7240 |
Removal of impacted tooth - completely bony |
259 |
86 |
$57K |
| D1110 |
Prophylaxis - adult |
1,241 |
1,218 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,539 |
2,495 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,599 |
1,579 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,273 |
3,022 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
199 |
31 |
$24K |
| D1120 |
Prophylaxis - child |
771 |
761 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
686 |
674 |
$20K |
| D5130 |
|
12 |
12 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
197 |
193 |
$5K |
| D0272 |
Bitewings - two radiographic images |
248 |
248 |
$4K |
| D2394 |
|
20 |
13 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
12 |
$2K |
| D2332 |
|
20 |
12 |
$2K |
| D2330 |
|
20 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
39 |
13 |
$951.60 |
| D0350 |
|
29 |
29 |
$823.23 |
| D5411 |
|
17 |
16 |
$570.31 |
| D5410 |
|
14 |
12 |
$507.64 |