| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,183 |
6,172 |
$345K |
| D1120 |
Prophylaxis - child |
6,180 |
6,153 |
$233K |
| D0230 |
Intraoral - periapical each additional radiographic image |
37,121 |
7,096 |
$150K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,057 |
1,103 |
$138K |
| D8670 |
Periodic orthodontic treatment visit |
429 |
429 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,317 |
1,309 |
$83K |
| D0272 |
Bitewings - two radiographic images |
5,186 |
5,166 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,665 |
5,647 |
$60K |
| D9430 |
|
1,458 |
1,436 |
$46K |
| D1351 |
Sealant - per tooth |
1,568 |
505 |
$45K |
| D2160 |
|
477 |
298 |
$38K |
| D0350 |
|
3,832 |
1,490 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
503 |
246 |
$34K |
| D2140 |
|
597 |
375 |
$33K |
| D9993 |
|
401 |
400 |
$26K |
| D1110 |
Prophylaxis - adult |
302 |
301 |
$25K |
| D1310 |
|
528 |
527 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,114 |
1,108 |
$24K |
| D0330 |
Panoramic radiographic image |
790 |
787 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,513 |
1,490 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
258 |
148 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
76 |
40 |
$9K |
| D0340 |
|
160 |
160 |
$8K |
| D1206 |
Topical application of fluoride varnish |
370 |
366 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
195 |
195 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
56 |
29 |
$6K |
| D0603 |
|
270 |
269 |
$4K |
| D7111 |
|
60 |
41 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D4910 |
|
13 |
13 |
$1K |