| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,903 |
5,875 |
$331K |
| D1120 |
Prophylaxis - child |
6,720 |
6,638 |
$267K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,693 |
1,673 |
$244K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,757 |
3,746 |
$235K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
423 |
241 |
$201K |
| D0230 |
Intraoral - periapical each additional radiographic image |
41,454 |
8,662 |
$179K |
| D0210 |
Intraoral - complete series of radiographic images |
2,716 |
2,689 |
$126K |
| D4341 |
|
1,639 |
430 |
$115K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,251 |
7,168 |
$98K |
| D1351 |
Sealant - per tooth |
2,615 |
801 |
$88K |
| D0350 |
|
7,610 |
3,404 |
$85K |
| D1110 |
Prophylaxis - adult |
960 |
960 |
$85K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,376 |
660 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,451 |
750 |
$78K |
| D9430 |
|
2,333 |
2,238 |
$74K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,485 |
1,464 |
$58K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
831 |
329 |
$56K |
| D4910 |
|
726 |
722 |
$55K |
| D0340 |
|
913 |
913 |
$45K |
| D1310 |
|
993 |
990 |
$45K |
| D2954 |
|
421 |
242 |
$44K |
| D0272 |
Bitewings - two radiographic images |
2,990 |
2,950 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
431 |
283 |
$34K |
| D0330 |
Panoramic radiographic image |
1,124 |
1,124 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,544 |
2,502 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,400 |
1,393 |
$30K |
| D4260 |
|
51 |
14 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
210 |
93 |
$25K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
53 |
40 |
$25K |
| D1320 |
|
1,288 |
1,279 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
108 |
52 |
$13K |
| D0603 |
|
851 |
847 |
$12K |
| D1206 |
Topical application of fluoride varnish |
709 |
709 |
$11K |
| D2740 |
Crown - porcelain/ceramic |
23 |
14 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
104 |
50 |
$10K |
| D2160 |
|
71 |
41 |
$6K |
| D9993 |
|
75 |
75 |
$5K |
| D0270 |
|
201 |
200 |
$981.25 |