| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
13,563 |
13,352 |
$375K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,708 |
2,652 |
$372K |
| D1110 |
Prophylaxis - adult |
6,408 |
6,341 |
$339K |
| D1120 |
Prophylaxis - child |
7,500 |
7,367 |
$261K |
| D1351 |
Sealant - per tooth |
9,329 |
2,133 |
$252K |
| D1206 |
Topical application of fluoride varnish |
13,719 |
13,507 |
$194K |
| D0274 |
Bitewings - four radiographic images |
5,687 |
5,615 |
$170K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,473 |
11,079 |
$139K |
| D0220 |
Intraoral - periapical first radiographic image |
12,017 |
11,742 |
$136K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
907 |
383 |
$127K |
| D0272 |
Bitewings - two radiographic images |
6,015 |
5,895 |
$122K |
| D9248 |
|
366 |
355 |
$41K |
| D0330 |
Panoramic radiographic image |
1,594 |
1,565 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,253 |
1,202 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
248 |
169 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
223 |
223 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
97 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
92 |
$10K |
| D2140 |
|
97 |
60 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
109 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
39 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$213.72 |
| D1330 |
|
16,205 |
16,006 |
$0.06 |
| D0603 |
|
17,002 |
16,768 |
$0.00 |
| D1310 |
|
16,245 |
16,059 |
$0.00 |
| D0602 |
|
44 |
44 |
$0.00 |