| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,452 |
8,114 |
$276K |
| D1206 |
Topical application of fluoride varnish |
12,212 |
11,728 |
$237K |
| D8670 |
Periodic orthodontic treatment visit |
2,249 |
2,000 |
$184K |
| D0120 |
Periodic oral evaluation - established patient |
6,728 |
6,463 |
$161K |
| D1110 |
Prophylaxis - adult |
3,754 |
3,633 |
$154K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,215 |
854 |
$149K |
| D0330 |
Panoramic radiographic image |
2,280 |
2,165 |
$137K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,031 |
2,907 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,296 |
736 |
$102K |
| D1351 |
Sealant - per tooth |
2,518 |
850 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
417 |
281 |
$26K |
| D9248 |
|
168 |
155 |
$25K |
| D0272 |
Bitewings - two radiographic images |
724 |
699 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
478 |
447 |
$15K |
| D2140 |
|
216 |
160 |
$13K |
| D9110 |
|
175 |
166 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
69 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
44 |
39 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
25 |
$340.60 |