| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
4,915 |
1,889 |
$750K |
| D1120 |
Prophylaxis - child |
15,784 |
15,036 |
$481K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,676 |
716 |
$448K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,804 |
1,541 |
$435K |
| D0120 |
Periodic oral evaluation - established patient |
18,918 |
18,025 |
$403K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,665 |
712 |
$335K |
| D1208 |
Topical application of fluoride, excluding varnish |
20,907 |
19,920 |
$318K |
| D1110 |
Prophylaxis - adult |
5,237 |
4,989 |
$239K |
| D0330 |
Panoramic radiographic image |
3,622 |
3,417 |
$177K |
| D0272 |
Bitewings - two radiographic images |
8,418 |
8,094 |
$154K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,949 |
4,650 |
$136K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,550 |
799 |
$104K |
| D0220 |
Intraoral - periapical first radiographic image |
1,830 |
1,740 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
896 |
857 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
833 |
807 |
$25K |
| D0145 |
Oral evaluation for a patient under three years of age |
674 |
635 |
$21K |
| D0274 |
Bitewings - four radiographic images |
380 |
380 |
$12K |
| D7111 |
|
139 |
97 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
647 |
311 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
28 |
$5K |
| D2330 |
|
22 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
30 |
$878.40 |