| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,483 |
4,171 |
$794K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,114 |
3,533 |
$471K |
| D0120 |
Periodic oral evaluation - established patient |
13,037 |
13,010 |
$384K |
| D1120 |
Prophylaxis - child |
9,118 |
9,088 |
$373K |
| D1110 |
Prophylaxis - adult |
6,441 |
6,420 |
$330K |
| D1206 |
Topical application of fluoride varnish |
10,094 |
10,044 |
$271K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,305 |
1,259 |
$201K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
899 |
400 |
$176K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,118 |
891 |
$169K |
| D0274 |
Bitewings - four radiographic images |
4,045 |
4,024 |
$136K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,178 |
2,150 |
$110K |
| D0272 |
Bitewings - two radiographic images |
4,335 |
4,310 |
$108K |
| D0140 |
Limited oral evaluation - problem focused |
1,443 |
1,424 |
$67K |
| D2330 |
|
797 |
546 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
3,347 |
3,291 |
$58K |
| D1351 |
Sealant - per tooth |
1,836 |
645 |
$53K |
| D2331 |
|
480 |
372 |
$50K |
| D0240 |
|
1,780 |
967 |
$38K |
| D0330 |
Panoramic radiographic image |
506 |
505 |
$34K |
| D2332 |
|
179 |
120 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
221 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
358 |
351 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,269 |
870 |
$14K |
| D2335 |
|
70 |
50 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$318.00 |
| D0601 |
|
27 |
27 |
$0.00 |
| D0602 |
|
246 |
241 |
$0.00 |
| D0603 |
|
219 |
213 |
$0.00 |