| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,961 |
3,397 |
$665K |
| D0120 |
Periodic oral evaluation - established patient |
23,264 |
23,231 |
$541K |
| D1110 |
Prophylaxis - adult |
12,154 |
12,138 |
$530K |
| D1120 |
Prophylaxis - child |
13,761 |
13,741 |
$454K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,092 |
2,900 |
$427K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,342 |
1,313 |
$414K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,808 |
1,662 |
$279K |
| D0274 |
Bitewings - four radiographic images |
8,652 |
8,640 |
$253K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,478 |
16,455 |
$197K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,017 |
5,716 |
$187K |
| D1206 |
Topical application of fluoride varnish |
5,981 |
5,972 |
$124K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
682 |
591 |
$110K |
| D1351 |
Sealant - per tooth |
3,178 |
880 |
$110K |
| D0220 |
Intraoral - periapical first radiographic image |
7,347 |
7,251 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,272 |
2,267 |
$90K |
| D0140 |
Limited oral evaluation - problem focused |
2,564 |
2,548 |
$86K |
| D0272 |
Bitewings - two radiographic images |
4,122 |
4,109 |
$85K |
| D0330 |
Panoramic radiographic image |
1,049 |
1,049 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,802 |
2,790 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
663 |
656 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,164 |
1,163 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
427 |
141 |
$36K |
| D9420 |
|
70 |
70 |
$8K |
| D4342 |
|
22 |
13 |
$2K |