| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,769 |
1,632 |
$369K |
| D2394 |
|
884 |
545 |
$144K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
805 |
344 |
$103K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,855 |
2,620 |
$77K |
| D1120 |
Prophylaxis - child |
1,800 |
1,788 |
$54K |
| D1110 |
Prophylaxis - adult |
992 |
977 |
$46K |
| D0330 |
Panoramic radiographic image |
863 |
853 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,610 |
2,577 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,992 |
1,975 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,333 |
1,271 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
797 |
780 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,300 |
1,282 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
192 |
102 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
868 |
823 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
55 |
$8K |
| D1320 |
|
220 |
204 |
$8K |
| D0274 |
Bitewings - four radiographic images |
179 |
177 |
$6K |
| D2335 |
|
21 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$766.89 |
| D0602 |
|
68 |
65 |
$467.35 |
| D0601 |
|
25 |
25 |
$163.55 |