| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,501 |
2,492 |
$217K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
866 |
310 |
$214K |
| D1120 |
Prophylaxis - child |
3,437 |
3,430 |
$212K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
764 |
503 |
$157K |
| D1206 |
Topical application of fluoride varnish |
3,501 |
3,491 |
$135K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
755 |
450 |
$111K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,281 |
1,162 |
$105K |
| D1354 |
|
5,460 |
1,314 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
734 |
734 |
$60K |
| D0330 |
Panoramic radiographic image |
548 |
546 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
307 |
157 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,140 |
1,138 |
$44K |
| D1351 |
Sealant - per tooth |
806 |
357 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,350 |
1,304 |
$33K |
| D0240 |
|
774 |
411 |
$30K |
| D0145 |
Oral evaluation for a patient under three years of age |
361 |
360 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,333 |
774 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
290 |
$23K |
| D1110 |
Prophylaxis - adult |
202 |
202 |
$23K |
| D0603 |
|
2,025 |
2,019 |
$22K |
| D0274 |
Bitewings - four radiographic images |
252 |
252 |
$15K |
| D1355 |
|
1,751 |
376 |
$14K |
| D2390 |
|
28 |
12 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
25 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
24 |
$7K |
| D2330 |
|
20 |
12 |
$3K |
| D9920 |
|
109 |
109 |
$10.00 |
| D1330 |
|
273 |
270 |
$0.00 |
| D1310 |
|
270 |
267 |
$0.00 |
| D3120 |
|
67 |
44 |
$0.00 |
| D1999 |
|
260 |
248 |
$0.00 |