| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,527 |
5,425 |
$174K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
817 |
331 |
$120K |
| D0330 |
Panoramic radiographic image |
2,450 |
2,403 |
$114K |
| D1110 |
Prophylaxis - adult |
3,594 |
3,532 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,953 |
1,372 |
$95K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,471 |
1,266 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,417 |
1,483 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,974 |
2,931 |
$57K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
165 |
128 |
$53K |
| D1120 |
Prophylaxis - child |
3,496 |
3,436 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
1,060 |
1,049 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
387 |
315 |
$27K |
| D1351 |
Sealant - per tooth |
2,479 |
792 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
2,726 |
2,595 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
374 |
236 |
$13K |
| D8670 |
Periodic orthodontic treatment visit |
158 |
153 |
$9K |
| D1206 |
Topical application of fluoride varnish |
6,444 |
6,329 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,014 |
882 |
$8K |
| D2332 |
|
100 |
56 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,192 |
2,608 |
$5K |
| D1354 |
|
1,028 |
310 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
5,030 |
4,873 |
$5K |
| D2330 |
|
275 |
150 |
$4K |
| D1330 |
|
6,809 |
6,680 |
$4K |
| D2950 |
|
208 |
150 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,870 |
1,845 |
$3K |
| D2331 |
|
74 |
52 |
$2K |
| D0272 |
Bitewings - two radiographic images |
3,186 |
3,119 |
$2K |
| D4341 |
|
56 |
25 |
$1K |
| D3221 |
|
34 |
24 |
$1K |
| D0240 |
|
855 |
833 |
$809.51 |
| D2940 |
|
36 |
25 |
$701.37 |
| D4342 |
|
108 |
45 |
$699.45 |
| D0270 |
|
568 |
557 |
$307.90 |