| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
17,924 |
17,924 |
$487K |
| D1120 |
Prophylaxis - child |
16,277 |
16,277 |
$456K |
| D1206 |
Topical application of fluoride varnish |
12,539 |
12,539 |
$207K |
| D0272 |
Bitewings - two radiographic images |
8,801 |
8,801 |
$165K |
| D0330 |
Panoramic radiographic image |
2,972 |
2,972 |
$164K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,866 |
1,020 |
$150K |
| D1351 |
Sealant - per tooth |
5,354 |
1,424 |
$148K |
| D0274 |
Bitewings - four radiographic images |
4,380 |
4,380 |
$132K |
| D1110 |
Prophylaxis - adult |
2,985 |
2,985 |
$116K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,203 |
1,197 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,866 |
1,811 |
$104K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
977 |
551 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
4,636 |
4,627 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,442 |
6,442 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
798 |
600 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
566 |
389 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
1,040 |
1,025 |
$30K |
| D1354 |
|
3,209 |
673 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,895 |
2,758 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
408 |
261 |
$19K |
| D2160 |
|
170 |
116 |
$11K |
| D0240 |
|
427 |
427 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
78 |
78 |
$3K |
| D2140 |
|
33 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$71.45 |