| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,872 |
7,872 |
$216K |
| D1120 |
Prophylaxis - child |
7,160 |
7,160 |
$204K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,659 |
1,201 |
$136K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,518 |
618 |
$119K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,108 |
8,108 |
$110K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
963 |
428 |
$96K |
| D0330 |
Panoramic radiographic image |
1,786 |
1,784 |
$95K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,194 |
498 |
$79K |
| D0272 |
Bitewings - two radiographic images |
3,924 |
3,924 |
$74K |
| D0220 |
Intraoral - periapical first radiographic image |
6,359 |
6,260 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,181 |
5,600 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,321 |
725 |
$62K |
| D1351 |
Sealant - per tooth |
2,143 |
734 |
$60K |
| D2332 |
|
478 |
208 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
984 |
936 |
$56K |
| D1110 |
Prophylaxis - adult |
1,327 |
1,327 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
547 |
261 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,390 |
1,390 |
$40K |
| D2140 |
|
660 |
381 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
1,000 |
971 |
$28K |
| D2160 |
|
363 |
224 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
78 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
256 |
$7K |
| D9310 |
|
50 |
50 |
$3K |
| D2335 |
|
31 |
15 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$2K |
| D1206 |
Topical application of fluoride varnish |
197 |
197 |
$542.40 |
| D9985 |
|
624 |
577 |
$0.00 |