| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,176 |
10,085 |
$549K |
| D1120 |
Prophylaxis - child |
12,866 |
12,753 |
$481K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,989 |
4,948 |
$306K |
| D1351 |
Sealant - per tooth |
11,430 |
3,074 |
$305K |
| D0230 |
Intraoral - periapical each additional radiographic image |
73,156 |
13,716 |
$297K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,603 |
1,732 |
$237K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,918 |
576 |
$222K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,827 |
538 |
$178K |
| D1110 |
Prophylaxis - adult |
1,960 |
1,943 |
$157K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
320 |
208 |
$148K |
| D0274 |
Bitewings - four radiographic images |
6,863 |
6,813 |
$137K |
| D1206 |
Topical application of fluoride varnish |
5,548 |
5,504 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,078 |
8,010 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,763 |
1,740 |
$79K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,174 |
616 |
$66K |
| D8670 |
Periodic orthodontic treatment visit |
324 |
301 |
$64K |
| D1310 |
|
1,555 |
1,549 |
$63K |
| D0272 |
Bitewings - two radiographic images |
4,621 |
4,573 |
$50K |
| D2140 |
|
924 |
472 |
$48K |
| D9993 |
|
516 |
515 |
$31K |
| D2954 |
|
180 |
124 |
$18K |
| D0603 |
|
894 |
888 |
$13K |
| D2160 |
|
126 |
90 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
20 |
15 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
117 |
117 |
$8K |
| D0350 |
|
828 |
444 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
41 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
56 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
465 |
458 |
$5K |
| D3320 |
|
12 |
12 |
$4K |
| D9430 |
|
91 |
89 |
$2K |
| D0601 |
|
46 |
46 |
$585.00 |
| D0602 |
|
31 |
31 |
$450.00 |
| D9248 |
|
28 |
28 |
$245.00 |
| D0270 |
|
12 |
12 |
$60.00 |
| D1999 |
|
33 |
33 |
$0.00 |