| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,618 |
1,238 |
$156K |
| D9248 |
|
1,843 |
1,458 |
$129K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,633 |
1,013 |
$127K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,219 |
991 |
$109K |
| D1120 |
Prophylaxis - child |
3,197 |
2,907 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
4,456 |
4,050 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,526 |
4,174 |
$81K |
| D1110 |
Prophylaxis - adult |
1,717 |
1,618 |
$66K |
| D2330 |
|
1,169 |
327 |
$53K |
| D8670 |
Periodic orthodontic treatment visit |
628 |
594 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,686 |
1,379 |
$44K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
553 |
157 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
361 |
106 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,004 |
936 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,044 |
965 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,211 |
1,112 |
$18K |
| D0330 |
Panoramic radiographic image |
519 |
489 |
$18K |
| D1351 |
Sealant - per tooth |
792 |
321 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
518 |
465 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
870 |
746 |
$9K |
| D2335 |
|
49 |
12 |
$4K |
| D1206 |
Topical application of fluoride varnish |
184 |
153 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
368 |
155 |
$3K |
| D8660 |
|
28 |
28 |
$438.75 |
| D9420 |
|
517 |
450 |
$60.00 |