| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
15,890 |
15,889 |
$510K |
| D1120 |
Prophylaxis - child |
14,803 |
14,803 |
$503K |
| D0220 |
Intraoral - periapical first radiographic image |
14,375 |
14,351 |
$208K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,495 |
15,495 |
$206K |
| D0272 |
Bitewings - two radiographic images |
8,576 |
8,576 |
$195K |
| D0274 |
Bitewings - four radiographic images |
4,093 |
4,093 |
$152K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,263 |
10,023 |
$125K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,100 |
690 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
666 |
436 |
$41K |
| D0330 |
Panoramic radiographic image |
484 |
484 |
$33K |
| D1351 |
Sealant - per tooth |
853 |
308 |
$30K |
| D1110 |
Prophylaxis - adult |
669 |
669 |
$28K |
| D1206 |
Topical application of fluoride varnish |
951 |
951 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
80 |
$5K |
| D2140 |
|
43 |
29 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
19 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
12 |
$1K |