| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,320 |
5,234 |
$274K |
| D0120 |
Periodic oral evaluation - established patient |
3,167 |
3,167 |
$243K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,613 |
3,510 |
$240K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,637 |
1,347 |
$177K |
| D0230 |
Intraoral - periapical each additional radiographic image |
36,753 |
6,208 |
$154K |
| D1351 |
Sealant - per tooth |
3,650 |
1,352 |
$139K |
| D2140 |
|
2,288 |
1,313 |
$125K |
| D1110 |
Prophylaxis - adult |
1,439 |
1,418 |
$124K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,787 |
6,680 |
$114K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,863 |
968 |
$106K |
| D2160 |
|
906 |
582 |
$72K |
| D1310 |
|
1,522 |
1,502 |
$68K |
| D0272 |
Bitewings - two radiographic images |
4,836 |
4,753 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
420 |
173 |
$50K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
427 |
272 |
$49K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
387 |
160 |
$38K |
| D4341 |
|
526 |
137 |
$37K |
| D0350 |
|
3,370 |
1,744 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
624 |
618 |
$30K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
57 |
52 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,904 |
1,872 |
$23K |
| D0603 |
|
1,387 |
1,372 |
$20K |
| D2331 |
|
157 |
102 |
$12K |
| D2330 |
|
141 |
92 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
89 |
84 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
39 |
$3K |
| D2332 |
|
18 |
14 |
$1K |
| D9430 |
|
41 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$980.00 |