| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,595 |
2,595 |
$171K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,207 |
448 |
$144K |
| D1120 |
Prophylaxis - child |
2,866 |
2,866 |
$139K |
| D1351 |
Sealant - per tooth |
3,616 |
969 |
$137K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,139 |
419 |
$112K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,152 |
498 |
$77K |
| D1310 |
|
1,351 |
1,351 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,447 |
1,422 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
754 |
393 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,086 |
2,081 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
629 |
275 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,101 |
1,101 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
663 |
663 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,627 |
1,627 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
337 |
337 |
$20K |
| D2140 |
|
361 |
199 |
$20K |
| D0350 |
|
916 |
814 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,062 |
1,059 |
$13K |
| D0603 |
|
830 |
830 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
130 |
$12K |
| D0272 |
Bitewings - two radiographic images |
773 |
773 |
$9K |
| D1320 |
|
870 |
870 |
$9K |
| D2160 |
|
84 |
55 |
$7K |
| D0602 |
|
336 |
336 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
32 |
$5K |
| D2330 |
|
36 |
25 |
$3K |
| D2331 |
|
23 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$675.00 |