| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,241 |
7,922 |
$378K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,348 |
4,285 |
$250K |
| D1120 |
Prophylaxis - child |
7,183 |
6,959 |
$239K |
| D0210 |
Intraoral - complete series of radiographic images |
4,192 |
4,154 |
$187K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,762 |
9,390 |
$183K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,103 |
408 |
$117K |
| D0274 |
Bitewings - four radiographic images |
6,030 |
5,810 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,348 |
7,134 |
$79K |
| D1351 |
Sealant - per tooth |
2,816 |
676 |
$70K |
| D0350 |
|
5,549 |
2,328 |
$69K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
545 |
171 |
$64K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
631 |
206 |
$62K |
| D9430 |
|
1,656 |
1,583 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
872 |
305 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
671 |
310 |
$44K |
| D4341 |
|
650 |
243 |
$43K |
| D1110 |
Prophylaxis - adult |
415 |
408 |
$30K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
396 |
142 |
$26K |
| D1310 |
|
489 |
489 |
$22K |
| D9993 |
|
389 |
389 |
$20K |
| D0330 |
Panoramic radiographic image |
1,584 |
1,570 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
151 |
$17K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
30 |
27 |
$14K |
| D0272 |
Bitewings - two radiographic images |
795 |
788 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
160 |
158 |
$6K |
| D0603 |
|
339 |
339 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
128 |
$4K |
| D2160 |
|
31 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
265 |
$2K |
| D4910 |
|
24 |
24 |
$2K |
| D1206 |
Topical application of fluoride varnish |
98 |
93 |
$2K |
| D1354 |
|
36 |
36 |
$1K |
| D4342 |
|
28 |
13 |
$1K |
| D2140 |
|
21 |
12 |
$1K |
| D1320 |
|
12 |
12 |
$210.00 |
| D0601 |
|
12 |
12 |
$180.00 |
| D0270 |
|
28 |
28 |
$120.00 |
| D9248 |
|
15 |
15 |
$105.00 |
| D1330 |
|
599 |
463 |
$0.00 |