| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,137 |
5,137 |
$349K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,456 |
1,605 |
$346K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
994 |
681 |
$186K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,577 |
3,121 |
$176K |
| D1120 |
Prophylaxis - child |
3,682 |
3,681 |
$142K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,310 |
952 |
$141K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,208 |
800 |
$134K |
| D1351 |
Sealant - per tooth |
2,772 |
1,040 |
$129K |
| D0272 |
Bitewings - two radiographic images |
3,381 |
3,381 |
$100K |
| D1206 |
Topical application of fluoride varnish |
3,204 |
3,203 |
$89K |
| D0330 |
Panoramic radiographic image |
1,042 |
1,042 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
2,359 |
2,341 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,220 |
1,220 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
273 |
233 |
$50K |
| D1110 |
Prophylaxis - adult |
749 |
749 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
604 |
603 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,066 |
1,066 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
669 |
669 |
$20K |
| D9920 |
|
48 |
44 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
81 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
13 |
$2K |
| D0240 |
|
21 |
12 |
$421.80 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$261.25 |