| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,290 |
10,234 |
$631K |
| D1120 |
Prophylaxis - child |
14,574 |
14,493 |
$579K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
5,904 |
2,833 |
$391K |
| D0230 |
Intraoral - periapical each additional radiographic image |
74,229 |
15,215 |
$328K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,596 |
4,589 |
$303K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,211 |
2,203 |
$239K |
| D1208 |
Topical application of fluoride, excluding varnish |
16,538 |
16,449 |
$225K |
| D1351 |
Sealant - per tooth |
7,748 |
2,251 |
$215K |
| D1310 |
|
4,593 |
4,560 |
$208K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,643 |
662 |
$194K |
| D9993 |
|
2,678 |
2,675 |
$168K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
332 |
228 |
$157K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,537 |
622 |
$152K |
| D2140 |
|
2,648 |
1,524 |
$143K |
| D0274 |
Bitewings - four radiographic images |
6,354 |
6,334 |
$136K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
262 |
235 |
$121K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,011 |
2,956 |
$120K |
| D1110 |
Prophylaxis - adult |
902 |
902 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
1,587 |
1,584 |
$75K |
| D7240 |
Removal of impacted tooth - completely bony |
308 |
118 |
$71K |
| D0603 |
|
4,181 |
4,146 |
$62K |
| D9430 |
|
1,748 |
1,680 |
$56K |
| D0350 |
|
4,649 |
2,291 |
$47K |
| D0272 |
Bitewings - two radiographic images |
3,927 |
3,903 |
$45K |
| D1320 |
|
3,553 |
3,540 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,466 |
3,420 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
888 |
888 |
$31K |
| D2160 |
|
321 |
208 |
$25K |
| D4910 |
|
313 |
313 |
$24K |
| D0330 |
Panoramic radiographic image |
793 |
793 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
303 |
303 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
154 |
78 |
$18K |
| D1510 |
|
91 |
63 |
$18K |
| D3320 |
|
47 |
39 |
$17K |
| D2952 |
|
143 |
111 |
$15K |
| D4341 |
|
101 |
28 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
66 |
$6K |
| D0602 |
|
212 |
212 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
17 |
$2K |
| D0601 |
|
102 |
102 |
$2K |
| D1206 |
Topical application of fluoride varnish |
123 |
123 |
$594.00 |