| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,703 |
6,688 |
$370K |
| D2740 |
Crown - porcelain/ceramic |
666 |
481 |
$316K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,371 |
2,556 |
$291K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,996 |
681 |
$234K |
| D1120 |
Prophylaxis - child |
5,802 |
5,780 |
$220K |
| D1110 |
Prophylaxis - adult |
2,152 |
2,149 |
$179K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,619 |
2,610 |
$158K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,936 |
1,543 |
$157K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35,985 |
6,791 |
$145K |
| D0210 |
Intraoral - complete series of radiographic images |
2,964 |
2,954 |
$134K |
| D4910 |
|
1,320 |
1,318 |
$100K |
| D1351 |
Sealant - per tooth |
3,338 |
1,043 |
$93K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,369 |
7,345 |
$88K |
| D0274 |
Bitewings - four radiographic images |
4,101 |
4,083 |
$86K |
| D9110 |
|
1,338 |
1,328 |
$84K |
| D0350 |
|
6,758 |
2,980 |
$71K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
892 |
637 |
$70K |
| D4341 |
|
1,019 |
307 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,144 |
432 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,622 |
1,442 |
$63K |
| D9430 |
|
1,922 |
1,856 |
$55K |
| D0330 |
Panoramic radiographic image |
1,705 |
1,705 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
2,019 |
1,931 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,640 |
1,637 |
$19K |
| D2330 |
|
171 |
112 |
$13K |
| D9220 |
|
44 |
44 |
$9K |
| D5130 |
|
13 |
13 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
12 |
$7K |
| D4342 |
|
81 |
24 |
$3K |
| D2394 |
|
13 |
12 |
$1K |
| D9221 |
|
46 |
44 |
$828.44 |
| D1320 |
|
58 |
58 |
$322.50 |