| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,450 |
8,425 |
$455K |
| D1120 |
Prophylaxis - child |
8,470 |
8,436 |
$306K |
| D2140 |
|
5,185 |
2,029 |
$279K |
| D1110 |
Prophylaxis - adult |
2,782 |
2,773 |
$229K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44,862 |
8,913 |
$198K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,830 |
2,818 |
$175K |
| D8670 |
Periodic orthodontic treatment visit |
617 |
615 |
$173K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,571 |
1,254 |
$171K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,764 |
11,720 |
$139K |
| D0210 |
Intraoral - complete series of radiographic images |
2,826 |
2,819 |
$133K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,957 |
830 |
$112K |
| D1351 |
Sealant - per tooth |
3,511 |
1,204 |
$90K |
| D4341 |
|
1,307 |
357 |
$86K |
| D0274 |
Bitewings - four radiographic images |
3,628 |
3,611 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
563 |
217 |
$61K |
| D2740 |
Crown - porcelain/ceramic |
125 |
89 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,501 |
1,478 |
$58K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
507 |
206 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
882 |
375 |
$47K |
| D0272 |
Bitewings - two radiographic images |
3,294 |
3,285 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
231 |
189 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
374 |
204 |
$25K |
| D1310 |
|
519 |
518 |
$23K |
| D9993 |
|
293 |
293 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,185 |
1,177 |
$14K |
| D4910 |
|
104 |
104 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
207 |
207 |
$7K |
| D4342 |
|
125 |
43 |
$5K |
| D2160 |
|
54 |
30 |
$4K |
| D2330 |
|
30 |
16 |
$2K |
| D0603 |
|
128 |
128 |
$2K |
| D1320 |
|
100 |
100 |
$2K |
| D9430 |
|
12 |
12 |
$384.00 |