| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
1,592 |
1,563 |
$168K |
| D1110 |
Prophylaxis - adult |
2,651 |
2,586 |
$157K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,243 |
1,536 |
$149K |
| D1120 |
Prophylaxis - child |
4,343 |
4,232 |
$121K |
| D1351 |
Sealant - per tooth |
8,893 |
2,285 |
$85K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,530 |
1,037 |
$53K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,326 |
3,015 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
306 |
251 |
$45K |
| D0272 |
Bitewings - two radiographic images |
4,825 |
4,711 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
799 |
775 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
6,194 |
6,042 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
290 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,888 |
1,839 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,752 |
6,600 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
300 |
198 |
$15K |
| D1330 |
|
7,027 |
6,849 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
259 |
212 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
298 |
292 |
$4K |
| D1510 |
|
13 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
663 |
643 |
$2K |
| D1354 |
|
1,309 |
496 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
39 |
39 |
$905.00 |
| D2140 |
|
30 |
26 |
$690.86 |
| D0999 |
Unspecified diagnostic procedure, by report |
12 |
12 |
$240.00 |
| D9995 |
|
18 |
18 |
$160.00 |
| D3120 |
|
29 |
28 |
$16.00 |
| D9986 |
|
92 |
82 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
295 |
285 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$0.00 |