| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
11,856 |
11,822 |
$613K |
| D1120 |
Prophylaxis - child |
12,361 |
12,319 |
$444K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,555 |
2,225 |
$237K |
| D0230 |
Intraoral - periapical each additional radiographic image |
56,277 |
13,961 |
$225K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,314 |
680 |
$156K |
| D1351 |
Sealant - per tooth |
4,840 |
1,332 |
$139K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,109 |
2,107 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,465 |
12,423 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,682 |
903 |
$112K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,129 |
582 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,755 |
1,012 |
$101K |
| D0274 |
Bitewings - four radiographic images |
4,713 |
4,696 |
$98K |
| D2740 |
Crown - porcelain/ceramic |
205 |
137 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
7,711 |
7,661 |
$90K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
733 |
473 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
762 |
458 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
707 |
707 |
$34K |
| D1110 |
Prophylaxis - adult |
367 |
367 |
$32K |
| D0350 |
|
2,358 |
1,313 |
$23K |
| D4341 |
|
218 |
66 |
$15K |
| D2160 |
|
177 |
138 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
167 |
113 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
220 |
220 |
$13K |
| D2140 |
|
195 |
131 |
$11K |
| D7240 |
Removal of impacted tooth - completely bony |
41 |
12 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
139 |
135 |
$6K |
| D9430 |
|
127 |
127 |
$4K |
| D1206 |
Topical application of fluoride varnish |
222 |
222 |
$4K |
| D0272 |
Bitewings - two radiographic images |
328 |
328 |
$4K |
| D1310 |
|
80 |
80 |
$4K |
| D2331 |
|
19 |
12 |
$2K |
| D4910 |
|
15 |
15 |
$1K |
| D0603 |
|
32 |
32 |
$435.00 |
| D0601 |
|
13 |
13 |
$195.00 |