| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,149 |
4,132 |
$257K |
| D0120 |
Periodic oral evaluation - established patient |
4,055 |
4,031 |
$208K |
| D1120 |
Prophylaxis - child |
4,538 |
4,487 |
$163K |
| D0210 |
Intraoral - complete series of radiographic images |
3,031 |
3,019 |
$139K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,668 |
732 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,475 |
5,366 |
$92K |
| D2740 |
Crown - porcelain/ceramic |
176 |
112 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,361 |
5,325 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,636 |
2,607 |
$54K |
| D1351 |
Sealant - per tooth |
1,892 |
448 |
$53K |
| D1110 |
Prophylaxis - adult |
274 |
272 |
$24K |
| D7240 |
Removal of impacted tooth - completely bony |
105 |
40 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
418 |
199 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
493 |
427 |
$19K |
| D4910 |
|
215 |
214 |
$16K |
| D4341 |
|
134 |
38 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
28 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
28 |
$5K |
| D0272 |
Bitewings - two radiographic images |
460 |
450 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
12 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
25 |
$4K |
| D9220 |
|
15 |
14 |
$3K |
| D2954 |
|
22 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
25 |
$2K |
| D0350 |
|
230 |
108 |
$2K |
| D9221 |
|
15 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
289 |
288 |
$1K |
| D9241 |
|
24 |
24 |
$1K |
| D9430 |
|
36 |
36 |
$1K |
| D1206 |
Topical application of fluoride varnish |
110 |
105 |
$994.00 |
| D9242 |
|
12 |
12 |
$354.00 |