| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
11,977 |
11,876 |
$350K |
| D1206 |
Topical application of fluoride varnish |
13,909 |
13,783 |
$305K |
| D1120 |
Prophylaxis - child |
9,191 |
9,122 |
$266K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,769 |
2,164 |
$254K |
| D1110 |
Prophylaxis - adult |
5,221 |
5,166 |
$231K |
| D0274 |
Bitewings - four radiographic images |
6,398 |
6,326 |
$207K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,711 |
2,158 |
$199K |
| D0330 |
Panoramic radiographic image |
2,793 |
2,777 |
$175K |
| D1351 |
Sealant - per tooth |
6,908 |
2,492 |
$164K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,948 |
2,271 |
$160K |
| D0272 |
Bitewings - two radiographic images |
3,514 |
3,498 |
$95K |
| D0140 |
Limited oral evaluation - problem focused |
2,856 |
2,751 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,894 |
2,866 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
4,236 |
4,083 |
$53K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,885 |
2,691 |
$48K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
661 |
576 |
$47K |
| D1330 |
|
2,798 |
2,752 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
238 |
210 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,847 |
1,229 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
377 |
375 |
$11K |
| D2140 |
|
157 |
134 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
87 |
77 |
$8K |
| D2331 |
|
75 |
50 |
$6K |
| D4355 |
|
13 |
13 |
$626.72 |
| D2330 |
|
33 |
25 |
$79.84 |