| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
12,628 |
12,539 |
$597K |
| D1110 |
Prophylaxis - adult |
3,399 |
3,378 |
$224K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,073 |
798 |
$182K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,443 |
1,679 |
$175K |
| D1120 |
Prophylaxis - child |
10,610 |
10,537 |
$89K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,227 |
3,009 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,283 |
1,276 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,546 |
1,090 |
$59K |
| D1330 |
|
14,064 |
13,966 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,895 |
13,795 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,851 |
977 |
$20K |
| D1351 |
Sealant - per tooth |
2,922 |
891 |
$18K |
| D0272 |
Bitewings - two radiographic images |
11,857 |
11,772 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
681 |
672 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,991 |
12,724 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
13,385 |
13,261 |
$7K |
| D9920 |
|
79 |
78 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
12 |
$1K |
| D9420 |
|
26 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$993.50 |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
16 |
$400.00 |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$156.42 |
| D9986 |
|
46 |
45 |
$0.00 |