| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,679 |
8,514 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
531 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,400 |
1,438 |
$3K |
| D1120 |
Prophylaxis - child |
7,249 |
7,107 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
550 |
197 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
503 |
234 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,342 |
8,149 |
$1K |
| D0272 |
Bitewings - two radiographic images |
5,642 |
5,481 |
$978.90 |
| D0220 |
Intraoral - periapical first radiographic image |
8,854 |
8,536 |
$915.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
8,132 |
7,983 |
$883.35 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
35 |
12 |
$550.00 |
| D1206 |
Topical application of fluoride varnish |
1,441 |
1,392 |
$533.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
135 |
$500.00 |
| D1110 |
Prophylaxis - adult |
2,211 |
2,171 |
$460.94 |
| D0274 |
Bitewings - four radiographic images |
2,182 |
2,136 |
$288.16 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,349 |
1,232 |
$230.92 |
| D0140 |
Limited oral evaluation - problem focused |
512 |
472 |
$228.00 |
| D1351 |
Sealant - per tooth |
658 |
189 |
$187.00 |
| D0330 |
Panoramic radiographic image |
322 |
315 |
$110.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$48.00 |
| D0602 |
|
441 |
417 |
$0.00 |
| D9248 |
|
256 |
233 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
26 |
$0.00 |
| D1999 |
|
4,050 |
3,664 |
$0.00 |