| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,187 |
5,186 |
$220K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,528 |
1,158 |
$169K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39,252 |
6,949 |
$155K |
| D1120 |
Prophylaxis - child |
4,717 |
4,715 |
$143K |
| D0274 |
Bitewings - four radiographic images |
4,360 |
4,357 |
$92K |
| D2140 |
|
1,549 |
697 |
$83K |
| D1351 |
Sealant - per tooth |
2,249 |
771 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
736 |
736 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,761 |
4,759 |
$44K |
| D7111 |
|
758 |
388 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
941 |
940 |
$37K |
| D8670 |
Periodic orthodontic treatment visit |
107 |
106 |
$31K |
| D0350 |
|
2,460 |
1,321 |
$27K |
| D2160 |
|
341 |
200 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
142 |
71 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
112 |
57 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,096 |
1,095 |
$13K |
| D2330 |
|
144 |
86 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
744 |
$9K |
| D9993 |
|
139 |
139 |
$8K |
| D1310 |
|
139 |
139 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
39 |
$6K |
| D4341 |
|
52 |
13 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
83 |
$3K |
| D4910 |
|
27 |
27 |
$2K |
| D9430 |
|
27 |
26 |
$864.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$480.00 |
| D0603 |
|
26 |
26 |
$390.00 |