| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,601 |
4,595 |
$183K |
| D1120 |
Prophylaxis - child |
6,018 |
6,011 |
$176K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,650 |
880 |
$109K |
| D9993 |
|
1,320 |
1,320 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,824 |
5,816 |
$66K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
515 |
224 |
$60K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
591 |
290 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,005 |
522 |
$57K |
| D1310 |
|
1,321 |
1,321 |
$54K |
| D2140 |
|
1,016 |
501 |
$54K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,358 |
1,295 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
870 |
868 |
$52K |
| D1351 |
Sealant - per tooth |
2,030 |
685 |
$41K |
| D0272 |
Bitewings - two radiographic images |
3,406 |
3,397 |
$38K |
| D0145 |
Oral evaluation for a patient under three years of age |
649 |
649 |
$36K |
| D2330 |
|
368 |
186 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,840 |
3,452 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
160 |
$20K |
| D9420 |
|
201 |
171 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
134 |
$11K |
| D0603 |
|
694 |
693 |
$9K |
| D1354 |
|
632 |
333 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
536 |
532 |
$6K |
| D0601 |
|
337 |
337 |
$5K |
| D2160 |
|
55 |
40 |
$4K |
| D9430 |
|
139 |
138 |
$4K |
| D1206 |
Topical application of fluoride varnish |
219 |
219 |
$3K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$2K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$1K |
| D0602 |
|
73 |
73 |
$1K |
| D2941 |
|
23 |
13 |
$990.00 |
| D1352 |
|
35 |
22 |
$418.00 |
| D0350 |
|
49 |
41 |
$345.60 |