| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,390 |
2,444 |
$390K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,102 |
1,555 |
$283K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,956 |
592 |
$254K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,787 |
1,734 |
$239K |
| D1120 |
Prophylaxis - child |
4,898 |
4,776 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
6,117 |
5,958 |
$167K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,605 |
5,971 |
$153K |
| D1110 |
Prophylaxis - adult |
2,179 |
2,111 |
$111K |
| D1351 |
Sealant - per tooth |
4,358 |
1,105 |
$107K |
| D0220 |
Intraoral - periapical first radiographic image |
6,710 |
6,432 |
$77K |
| D0274 |
Bitewings - four radiographic images |
2,348 |
2,284 |
$75K |
| D9248 |
|
622 |
586 |
$62K |
| D1206 |
Topical application of fluoride varnish |
4,114 |
4,063 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,298 |
2,146 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,320 |
1,274 |
$42K |
| D0272 |
Bitewings - two radiographic images |
2,364 |
2,303 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,739 |
2,620 |
$37K |
| D0330 |
Panoramic radiographic image |
970 |
947 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
350 |
340 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
167 |
64 |
$13K |
| D2331 |
|
142 |
51 |
$13K |
| D2330 |
|
91 |
42 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
269 |
259 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
26 |
$2K |
| D7111 |
|
28 |
14 |
$286.75 |
| D0603 |
|
9,249 |
9,030 |
$0.00 |