| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,795 |
2,723 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
2,276 |
2,216 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,610 |
3,652 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,046 |
946 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,039 |
681 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
795 |
491 |
$5K |
| D1206 |
Topical application of fluoride varnish |
1,593 |
1,507 |
$5K |
| D0272 |
Bitewings - two radiographic images |
1,579 |
1,514 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,401 |
1,382 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
900 |
388 |
$3K |
| D1351 |
Sealant - per tooth |
1,910 |
598 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
340 |
250 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
537 |
452 |
$1K |
| D0274 |
Bitewings - four radiographic images |
1,086 |
1,036 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
165 |
120 |
$930.00 |
| D0210 |
Intraoral - complete series of radiographic images |
318 |
293 |
$704.00 |
| D9430 |
|
1,292 |
1,084 |
$600.00 |
| D1110 |
Prophylaxis - adult |
68 |
60 |
$490.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
366 |
272 |
$436.80 |
| D0350 |
|
24 |
12 |
$230.40 |
| D2140 |
|
38 |
26 |
$218.40 |
| D0330 |
Panoramic radiographic image |
298 |
265 |
$200.00 |
| D1510 |
|
51 |
42 |
$120.00 |
| D0270 |
|
606 |
516 |
$30.00 |
| D9993 |
|
511 |
488 |
$0.00 |
| D4921 |
|
1,523 |
442 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
330 |
224 |
$0.00 |
| D4341 |
|
36 |
12 |
$0.00 |
| D0603 |
|
358 |
338 |
$0.00 |
| D1330 |
|
4,025 |
3,668 |
$0.00 |
| D1310 |
|
537 |
512 |
$0.00 |
| D3120 |
|
32 |
19 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
167 |
120 |
$0.00 |
| D0601 |
|
18 |
18 |
$0.00 |