| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,785 |
2,773 |
$185K |
| D1120 |
Prophylaxis - child |
3,746 |
3,707 |
$175K |
| D1351 |
Sealant - per tooth |
4,666 |
1,127 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
1,988 |
1,957 |
$152K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,115 |
4,949 |
$120K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,709 |
813 |
$115K |
| D1110 |
Prophylaxis - adult |
1,032 |
1,024 |
$91K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
171 |
121 |
$81K |
| D1206 |
Topical application of fluoride varnish |
4,829 |
4,783 |
$78K |
| D2140 |
|
973 |
488 |
$53K |
| D0272 |
Bitewings - two radiographic images |
4,031 |
3,992 |
$48K |
| D4341 |
|
615 |
163 |
$43K |
| D1310 |
|
721 |
716 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
904 |
896 |
$11K |
| D9993 |
|
152 |
152 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
84 |
$9K |
| D4910 |
|
117 |
117 |
$9K |
| D0601 |
|
456 |
452 |
$7K |
| D4342 |
|
143 |
41 |
$6K |
| D2160 |
|
72 |
52 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
12 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
12 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
179 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$525.00 |