| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,296 |
7,267 |
$448K |
| D1120 |
Prophylaxis - child |
8,201 |
8,172 |
$339K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,164 |
4,156 |
$265K |
| D1351 |
Sealant - per tooth |
7,643 |
2,076 |
$230K |
| D0210 |
Intraoral - complete series of radiographic images |
3,481 |
3,476 |
$163K |
| D0230 |
Intraoral - periapical each additional radiographic image |
34,971 |
8,725 |
$149K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,005 |
1,166 |
$132K |
| D1310 |
|
2,616 |
2,605 |
$119K |
| D1110 |
Prophylaxis - adult |
1,160 |
1,154 |
$102K |
| D1206 |
Topical application of fluoride varnish |
4,903 |
4,892 |
$96K |
| D4910 |
|
1,189 |
1,180 |
$91K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,235 |
2,134 |
$87K |
| D0274 |
Bitewings - four radiographic images |
3,581 |
3,567 |
$77K |
| D0330 |
Panoramic radiographic image |
2,504 |
2,486 |
$74K |
| D9430 |
|
2,267 |
2,197 |
$72K |
| D9993 |
|
1,049 |
1,049 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,175 |
5,159 |
$61K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
422 |
156 |
$50K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
103 |
99 |
$48K |
| D4341 |
|
658 |
212 |
$44K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
396 |
137 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
321 |
186 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
661 |
427 |
$36K |
| D0603 |
|
2,324 |
2,318 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,851 |
2,739 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
548 |
246 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,361 |
2,352 |
$28K |
| D0350 |
|
2,580 |
1,476 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
279 |
214 |
$22K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
32 |
28 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
298 |
290 |
$10K |
| D1354 |
|
400 |
304 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
130 |
130 |
$9K |
| D7111 |
|
78 |
55 |
$4K |
| D0340 |
|
79 |
79 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
58 |
38 |
$4K |
| D4342 |
|
36 |
12 |
$2K |
| D0602 |
|
53 |
53 |
$780.00 |
| D0270 |
|
12 |
12 |
$55.00 |