| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,965 |
6,955 |
$322K |
| D1351 |
Sealant - per tooth |
10,457 |
2,596 |
$269K |
| D0230 |
Intraoral - periapical each additional radiographic image |
60,882 |
11,160 |
$256K |
| D1110 |
Prophylaxis - adult |
3,133 |
3,128 |
$251K |
| D1120 |
Prophylaxis - child |
6,416 |
6,408 |
$221K |
| D4341 |
|
3,042 |
837 |
$206K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,152 |
3,146 |
$194K |
| D0272 |
Bitewings - two radiographic images |
10,496 |
10,474 |
$123K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,531 |
9,519 |
$113K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,946 |
989 |
$111K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
231 |
172 |
$109K |
| D4910 |
|
991 |
985 |
$69K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,021 |
496 |
$68K |
| D9993 |
|
649 |
649 |
$36K |
| D4342 |
|
860 |
296 |
$36K |
| D1310 |
|
763 |
761 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
268 |
121 |
$31K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
248 |
109 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
347 |
161 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
137 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
94 |
69 |
$11K |
| D2954 |
|
68 |
54 |
$7K |
| D0601 |
|
301 |
300 |
$4K |
| D2140 |
|
73 |
47 |
$4K |
| D0274 |
Bitewings - four radiographic images |
169 |
169 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
83 |
83 |
$3K |
| D9430 |
|
73 |
70 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$1K |
| D2160 |
|
16 |
12 |
$1K |
| D0350 |
|
177 |
70 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
113 |
$1K |
| D0603 |
|
15 |
15 |
$225.00 |