| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,419 |
3,385 |
$105K |
| D1120 |
Prophylaxis - child |
2,685 |
2,641 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
644 |
510 |
$94K |
| D1110 |
Prophylaxis - adult |
1,675 |
1,667 |
$94K |
| D1206 |
Topical application of fluoride varnish |
3,926 |
3,845 |
$88K |
| D1351 |
Sealant - per tooth |
794 |
342 |
$53K |
| D8670 |
Periodic orthodontic treatment visit |
143 |
142 |
$46K |
| D9248 |
|
170 |
161 |
$46K |
| D0274 |
Bitewings - four radiographic images |
850 |
839 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
158 |
148 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
221 |
195 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
868 |
852 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
266 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
603 |
593 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,182 |
1,159 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
395 |
394 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
160 |
$25K |
| D1320 |
|
1,524 |
1,504 |
$23K |
| D0603 |
|
2,426 |
2,398 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
275 |
272 |
$18K |
| D0330 |
Panoramic radiographic image |
376 |
363 |
$17K |
| D1310 |
|
3,045 |
3,011 |
$17K |
| D1330 |
|
3,081 |
3,053 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
998 |
968 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
476 |
441 |
$9K |
| D2332 |
|
36 |
34 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
26 |
$5K |
| D2390 |
|
15 |
13 |
$4K |
| D2330 |
|
37 |
36 |
$4K |
| D1510 |
|
14 |
13 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
80 |
79 |
$2K |
| D8660 |
|
70 |
70 |
$2K |
| D2140 |
|
24 |
12 |
$2K |
| D0270 |
|
15 |
13 |
$276.00 |
| D0350 |
|
47 |
47 |
$0.00 |
| D0340 |
|
48 |
48 |
$0.00 |