| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,149 |
5,140 |
$327K |
| D0120 |
Periodic oral evaluation - established patient |
4,734 |
4,723 |
$270K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,922 |
1,021 |
$224K |
| D0210 |
Intraoral - complete series of radiographic images |
4,012 |
4,009 |
$188K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,372 |
1,340 |
$179K |
| D1120 |
Prophylaxis - child |
4,663 |
4,647 |
$173K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,455 |
1,255 |
$163K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,184 |
7,353 |
$136K |
| D1110 |
Prophylaxis - adult |
1,271 |
1,268 |
$107K |
| D9430 |
|
3,385 |
3,283 |
$107K |
| D0274 |
Bitewings - four radiographic images |
4,900 |
4,878 |
$96K |
| D0350 |
|
10,714 |
2,967 |
$80K |
| D7240 |
Removal of impacted tooth - completely bony |
305 |
138 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,185 |
5,166 |
$61K |
| D1351 |
Sealant - per tooth |
2,099 |
467 |
$61K |
| D0330 |
Panoramic radiographic image |
1,869 |
1,865 |
$37K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
77 |
60 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
617 |
260 |
$34K |
| D7230 |
|
151 |
88 |
$29K |
| D1320 |
|
1,471 |
1,463 |
$24K |
| D4341 |
|
305 |
104 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
166 |
110 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
336 |
336 |
$13K |
| D8670 |
Periodic orthodontic treatment visit |
38 |
38 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
384 |
383 |
$4K |
| D1310 |
|
107 |
107 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
115 |
$4K |
| D0272 |
Bitewings - two radiographic images |
355 |
355 |
$4K |
| D9993 |
|
70 |
70 |
$4K |
| D4910 |
|
52 |
50 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
13 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
12 |
$3K |
| D2954 |
|
14 |
13 |
$1K |
| D0270 |
|
132 |
132 |
$655.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$128.00 |