| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
10,199 |
10,172 |
$383K |
| D0120 |
Periodic oral evaluation - established patient |
15,007 |
14,983 |
$338K |
| D1120 |
Prophylaxis - child |
7,618 |
7,602 |
$307K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,462 |
2,419 |
$240K |
| D0274 |
Bitewings - four radiographic images |
11,274 |
11,266 |
$234K |
| D1351 |
Sealant - per tooth |
4,107 |
1,563 |
$199K |
| D0220 |
Intraoral - periapical first radiographic image |
20,064 |
19,954 |
$177K |
| D8670 |
Periodic orthodontic treatment visit |
722 |
706 |
$146K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,829 |
8,818 |
$120K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,539 |
1,667 |
$99K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,344 |
17,295 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,124 |
3,120 |
$76K |
| D0272 |
Bitewings - two radiographic images |
4,478 |
4,473 |
$63K |
| D1206 |
Topical application of fluoride varnish |
1,813 |
1,811 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
457 |
244 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
308 |
251 |
$25K |
| D1354 |
|
629 |
170 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
1,451 |
1,437 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
413 |
300 |
$14K |
| D9310 |
|
317 |
315 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
1,007 |
1,004 |
$9K |
| D1320 |
|
813 |
813 |
$7K |
| D8660 |
|
206 |
203 |
$5K |
| D9920 |
|
461 |
459 |
$5K |
| D0330 |
Panoramic radiographic image |
246 |
246 |
$5K |
| D0340 |
|
194 |
191 |
$5K |
| D2394 |
|
59 |
56 |
$4K |
| D2335 |
|
33 |
30 |
$3K |
| D9110 |
|
134 |
134 |
$2K |
| D0350 |
|
209 |
206 |
$2K |
| D2332 |
|
27 |
14 |
$1K |
| D0270 |
|
56 |
56 |
$497.64 |
| D1310 |
|
41 |
41 |
$0.00 |
| D1330 |
|
52 |
52 |
$0.00 |