| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
8,696 |
3,737 |
$847K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,270 |
2,593 |
$388K |
| D1351 |
Sealant - per tooth |
9,431 |
2,984 |
$250K |
| D1120 |
Prophylaxis - child |
7,135 |
6,994 |
$248K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,577 |
9,297 |
$236K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,557 |
433 |
$210K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,463 |
1,440 |
$199K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,138 |
5,005 |
$168K |
| D1110 |
Prophylaxis - adult |
2,987 |
2,922 |
$155K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,330 |
10,123 |
$145K |
| D0274 |
Bitewings - four radiographic images |
4,376 |
4,287 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
5,083 |
4,998 |
$141K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,106 |
4,953 |
$127K |
| D0220 |
Intraoral - periapical first radiographic image |
9,741 |
9,485 |
$114K |
| D0272 |
Bitewings - two radiographic images |
3,578 |
3,515 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
782 |
771 |
$51K |
| D0350 |
|
2,060 |
1,995 |
$36K |
| D9248 |
|
296 |
285 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
62 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
87 |
39 |
$7K |
| D2330 |
|
77 |
39 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
17 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
92 |
$863.88 |
| D0170 |
|
14 |
14 |
$99.24 |
| D0603 |
|
11,659 |
11,280 |
$0.00 |
| D0602 |
|
849 |
831 |
$0.00 |