| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,318 |
6,307 |
$351K |
| D1120 |
Prophylaxis - child |
5,922 |
5,910 |
$221K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45,219 |
8,301 |
$191K |
| D1110 |
Prophylaxis - adult |
1,866 |
1,860 |
$157K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,033 |
9,015 |
$111K |
| D2140 |
|
2,042 |
664 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,683 |
1,681 |
$107K |
| D1351 |
Sealant - per tooth |
3,552 |
1,131 |
$102K |
| D0272 |
Bitewings - two radiographic images |
7,212 |
7,200 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,381 |
543 |
$75K |
| D4341 |
|
1,009 |
277 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
949 |
482 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,088 |
494 |
$62K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
96 |
60 |
$45K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
484 |
266 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
658 |
658 |
$31K |
| D2740 |
Crown - porcelain/ceramic |
53 |
33 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
564 |
559 |
$22K |
| D8670 |
Periodic orthodontic treatment visit |
90 |
90 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
172 |
66 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
111 |
41 |
$13K |
| D9993 |
|
127 |
127 |
$8K |
| D1310 |
|
167 |
167 |
$8K |
| D2954 |
|
71 |
48 |
$7K |
| D4910 |
|
91 |
91 |
$7K |
| D2330 |
|
72 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
329 |
$4K |
| D2160 |
|
39 |
27 |
$3K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
15 |
$2K |
| D0350 |
|
59 |
29 |
$447.60 |
| D0603 |
|
12 |
12 |
$180.00 |