| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
4,086 |
1,188 |
$671K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,552 |
1,189 |
$469K |
| D2335 |
|
1,581 |
534 |
$260K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,201 |
575 |
$123K |
| D1120 |
Prophylaxis - child |
2,625 |
2,577 |
$122K |
| D1206 |
Topical application of fluoride varnish |
3,081 |
3,034 |
$78K |
| D3120 |
|
2,140 |
685 |
$73K |
| D7140 |
Extraction, erupted tooth or exposed root |
568 |
322 |
$73K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
368 |
122 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,119 |
1,099 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,923 |
1,898 |
$60K |
| D1351 |
Sealant - per tooth |
1,497 |
446 |
$54K |
| D2332 |
|
371 |
228 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,987 |
1,667 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
410 |
123 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,687 |
1,644 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
548 |
534 |
$25K |
| D0330 |
Panoramic radiographic image |
558 |
551 |
$25K |
| D1110 |
Prophylaxis - adult |
327 |
325 |
$21K |
| D2330 |
|
209 |
107 |
$18K |
| D0274 |
Bitewings - four radiographic images |
670 |
666 |
$16K |
| D1330 |
|
1,828 |
1,794 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
542 |
522 |
$6K |
| D0240 |
|
443 |
424 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
207 |
207 |
$3K |
| D2331 |
|
20 |
12 |
$2K |