| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,660 |
8,660 |
$256K |
| D1120 |
Prophylaxis - child |
7,973 |
7,973 |
$249K |
| D1206 |
Topical application of fluoride varnish |
8,629 |
8,629 |
$126K |
| D0272 |
Bitewings - two radiographic images |
3,503 |
3,501 |
$76K |
| D0274 |
Bitewings - four radiographic images |
1,724 |
1,724 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
3,618 |
3,597 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,088 |
3,008 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
443 |
419 |
$25K |
| D1110 |
Prophylaxis - adult |
539 |
539 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
469 |
465 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
112 |
49 |
$10K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$7K |
| D1354 |
|
1,069 |
386 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
108 |
77 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
791 |
791 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
49 |
14 |
$1K |