| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,903 |
2,234 |
$752K |
| D1351 |
Sealant - per tooth |
29,459 |
5,544 |
$743K |
| D0145 |
Oral evaluation for a patient under three years of age |
4,286 |
4,221 |
$579K |
| D0120 |
Periodic oral evaluation - established patient |
16,059 |
15,838 |
$445K |
| D1120 |
Prophylaxis - child |
12,158 |
11,998 |
$425K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,155 |
677 |
$303K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,239 |
15,656 |
$271K |
| D1110 |
Prophylaxis - adult |
5,133 |
5,049 |
$266K |
| D0220 |
Intraoral - periapical first radiographic image |
16,924 |
16,591 |
$200K |
| D1206 |
Topical application of fluoride varnish |
13,624 |
13,436 |
$191K |
| D0274 |
Bitewings - four radiographic images |
5,554 |
5,468 |
$181K |
| D0272 |
Bitewings - two radiographic images |
8,427 |
8,295 |
$171K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,141 |
580 |
$84K |
| D9248 |
|
630 |
613 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,823 |
3,781 |
$55K |
| D0330 |
Panoramic radiographic image |
1,147 |
1,122 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,249 |
1,221 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,401 |
1,351 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
211 |
211 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
722 |
703 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
120 |
51 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
38 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
37 |
$3K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
42 |
24 |
$2K |
| D9222 |
|
24 |
24 |
$1K |
| D9243 |
|
34 |
12 |
$983.94 |
| D9239 |
|
12 |
12 |
$627.44 |
| D9610 |
|
36 |
36 |
$572.06 |
| D0160 |
|
25 |
25 |
$357.31 |
| D0603 |
|
22,492 |
22,223 |
$0.00 |