| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
15,719 |
15,681 |
$834K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
9,686 |
4,255 |
$648K |
| D1120 |
Prophylaxis - child |
13,934 |
13,893 |
$511K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124,560 |
21,763 |
$497K |
| D2140 |
|
5,784 |
2,938 |
$314K |
| D0274 |
Bitewings - four radiographic images |
14,575 |
14,531 |
$309K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,631 |
14,587 |
$164K |
| D0350 |
|
14,794 |
7,026 |
$154K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,278 |
583 |
$148K |
| D2160 |
|
1,845 |
1,064 |
$146K |
| D7111 |
|
2,451 |
1,231 |
$140K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,130 |
2,129 |
$128K |
| D1351 |
Sealant - per tooth |
4,803 |
1,989 |
$119K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,083 |
446 |
$107K |
| D4910 |
|
1,313 |
1,308 |
$101K |
| D8670 |
Periodic orthodontic treatment visit |
347 |
346 |
$101K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
653 |
366 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
981 |
473 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,078 |
499 |
$59K |
| D2330 |
|
652 |
359 |
$50K |
| D7240 |
Removal of impacted tooth - completely bony |
193 |
78 |
$45K |
| D0272 |
Bitewings - two radiographic images |
3,673 |
3,671 |
$43K |
| D4341 |
|
471 |
133 |
$32K |
| D9993 |
|
479 |
479 |
$31K |
| D1310 |
|
558 |
558 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,108 |
1,107 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
343 |
343 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
189 |
$8K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$6K |
| D0603 |
|
290 |
290 |
$4K |
| D9430 |
|
95 |
94 |
$3K |
| D2390 |
|
25 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$2K |
| D4342 |
|
32 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$450.00 |