| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,271 |
12,956 |
$665K |
| D1208 |
Topical application of fluoride, excluding varnish |
20,894 |
20,392 |
$604K |
| D8670 |
Periodic orthodontic treatment visit |
1,865 |
1,796 |
$482K |
| D0120 |
Periodic oral evaluation - established patient |
12,480 |
12,154 |
$355K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,178 |
1,513 |
$351K |
| D0140 |
Limited oral evaluation - problem focused |
6,586 |
6,420 |
$303K |
| D1351 |
Sealant - per tooth |
4,251 |
1,326 |
$167K |
| D0272 |
Bitewings - two radiographic images |
4,972 |
4,866 |
$148K |
| D1110 |
Prophylaxis - adult |
2,121 |
2,070 |
$143K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,954 |
1,926 |
$114K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,260 |
530 |
$110K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,107 |
572 |
$106K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,450 |
3,131 |
$70K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
535 |
276 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,281 |
1,269 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
2,837 |
2,730 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
445 |
276 |
$40K |
| D0330 |
Panoramic radiographic image |
431 |
427 |
$36K |
| D8680 |
|
296 |
250 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
114 |
47 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,187 |
918 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
55 |
27 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$3K |
| D9310 |
|
32 |
32 |
$2K |
| D2160 |
|
14 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$648.53 |