| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12,876 |
7,240 |
$1.77M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,537 |
2,520 |
$1.16M |
| D1120 |
Prophylaxis - child |
29,877 |
29,428 |
$1.05M |
| D0120 |
Periodic oral evaluation - established patient |
32,406 |
31,987 |
$833K |
| D1206 |
Topical application of fluoride varnish |
33,050 |
32,568 |
$735K |
| D1351 |
Sealant - per tooth |
16,122 |
5,297 |
$491K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,676 |
3,959 |
$465K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,383 |
1,804 |
$431K |
| D1310 |
|
10,176 |
10,082 |
$410K |
| D1110 |
Prophylaxis - adult |
6,453 |
6,350 |
$341K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
10,947 |
9,309 |
$332K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,628 |
2,270 |
$270K |
| D2929 |
|
1,240 |
314 |
$258K |
| D1330 |
|
10,174 |
10,081 |
$242K |
| D0272 |
Bitewings - two radiographic images |
9,819 |
9,688 |
$217K |
| D0220 |
Intraoral - periapical first radiographic image |
11,193 |
10,939 |
$205K |
| D0240 |
|
9,398 |
9,252 |
$201K |
| D0274 |
Bitewings - four radiographic images |
4,704 |
4,653 |
$176K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,536 |
4,460 |
$157K |
| D0425 |
|
3,521 |
3,486 |
$151K |
| D0330 |
Panoramic radiographic image |
2,558 |
2,532 |
$144K |
| D0140 |
Limited oral evaluation - problem focused |
3,187 |
3,040 |
$113K |
| D2332 |
|
885 |
621 |
$108K |
| D1353 |
|
4,115 |
1,686 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,360 |
6,529 |
$81K |
| D9420 |
|
692 |
688 |
$63K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
490 |
312 |
$50K |
| D2390 |
|
179 |
61 |
$40K |
| D3120 |
|
1,018 |
752 |
$34K |
| D0601 |
|
1,920 |
1,902 |
$20K |
| D2331 |
|
172 |
134 |
$18K |
| D9630 |
|
923 |
911 |
$14K |
| D9945 |
|
39 |
39 |
$9K |
| D2330 |
|
121 |
84 |
$9K |
| D0603 |
|
362 |
357 |
$4K |
| D0602 |
|
334 |
324 |
$3K |
| D7961 |
|
12 |
12 |
$3K |
| D2394 |
|
17 |
13 |
$2K |
| D9995 |
|
32 |
30 |
$777.35 |
| D1354 |
|
31 |
14 |
$602.48 |
| D0270 |
|
12 |
12 |
$208.55 |