| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
21,012 |
21,011 |
$590K |
| D1120 |
Prophylaxis - child |
20,165 |
20,164 |
$583K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,891 |
1,522 |
$401K |
| D1206 |
Topical application of fluoride varnish |
23,924 |
23,923 |
$354K |
| D0272 |
Bitewings - two radiographic images |
15,573 |
15,573 |
$297K |
| D0330 |
Panoramic radiographic image |
3,548 |
3,548 |
$191K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,088 |
3,034 |
$176K |
| D1110 |
Prophylaxis - adult |
3,296 |
3,296 |
$136K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,538 |
1,381 |
$136K |
| D1351 |
Sealant - per tooth |
4,302 |
1,032 |
$121K |
| D0274 |
Bitewings - four radiographic images |
2,978 |
2,978 |
$93K |
| D0220 |
Intraoral - periapical first radiographic image |
7,714 |
7,673 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
933 |
594 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,386 |
1,386 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
1,145 |
1,139 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
419 |
223 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,180 |
590 |
$11K |
| D1354 |
|
1,162 |
287 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
36 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$447.92 |