| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,478 |
7,478 |
$414K |
| D1110 |
Prophylaxis - adult |
3,340 |
3,336 |
$278K |
| D1120 |
Prophylaxis - child |
5,984 |
5,981 |
$225K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,380 |
1,702 |
$221K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30,157 |
7,443 |
$172K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
340 |
250 |
$161K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,296 |
2,294 |
$143K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,122 |
763 |
$132K |
| D0210 |
Intraoral - complete series of radiographic images |
2,554 |
2,551 |
$118K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,451 |
9,443 |
$116K |
| D1351 |
Sealant - per tooth |
4,287 |
1,207 |
$115K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,020 |
963 |
$115K |
| D0274 |
Bitewings - four radiographic images |
5,071 |
5,067 |
$105K |
| D2140 |
|
1,270 |
740 |
$68K |
| D2160 |
|
778 |
479 |
$60K |
| D9430 |
|
1,378 |
1,319 |
$43K |
| D4341 |
|
612 |
163 |
$42K |
| D2954 |
|
397 |
299 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
2,646 |
2,605 |
$31K |
| D1310 |
|
671 |
661 |
$30K |
| D9993 |
|
449 |
440 |
$28K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
39 |
37 |
$18K |
| D0350 |
|
1,404 |
757 |
$13K |
| D2931 |
|
68 |
54 |
$9K |
| D0272 |
Bitewings - two radiographic images |
543 |
543 |
$6K |
| D0603 |
|
252 |
247 |
$4K |
| D2330 |
|
40 |
24 |
$3K |
| D4910 |
|
38 |
38 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D2161 |
|
16 |
13 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$308.00 |
| D0602 |
|
12 |
12 |
$150.00 |