| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
11,445 |
4,491 |
$861K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
8,395 |
3,689 |
$810K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,425 |
3,388 |
$475K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,074 |
406 |
$302K |
| D0120 |
Periodic oral evaluation - established patient |
10,125 |
10,036 |
$285K |
| D1120 |
Prophylaxis - child |
6,961 |
6,895 |
$246K |
| D1110 |
Prophylaxis - adult |
3,678 |
3,644 |
$194K |
| D0274 |
Bitewings - four radiographic images |
5,578 |
5,528 |
$188K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,823 |
10,026 |
$155K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,909 |
10,804 |
$154K |
| D2330 |
|
1,849 |
1,203 |
$134K |
| D0220 |
Intraoral - periapical first radiographic image |
10,360 |
10,250 |
$127K |
| D1351 |
Sealant - per tooth |
4,577 |
1,874 |
$120K |
| D0272 |
Bitewings - two radiographic images |
2,945 |
2,913 |
$67K |
| D9248 |
|
449 |
447 |
$54K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
579 |
158 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,072 |
1,053 |
$36K |
| D7240 |
Removal of impacted tooth - completely bony |
73 |
27 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
583 |
566 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
144 |
140 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
51 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
41 |
$5K |
| D0350 |
|
175 |
175 |
$3K |
| D1999 |
|
879 |
849 |
$0.00 |
| D0603 |
|
15,288 |
15,097 |
$0.00 |