| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
17,566 |
15,754 |
$672K |
| D0120 |
Periodic oral evaluation - established patient |
12,372 |
11,109 |
$359K |
| D1206 |
Topical application of fluoride varnish |
14,478 |
13,078 |
$351K |
| D8670 |
Periodic orthodontic treatment visit |
3,388 |
3,282 |
$237K |
| D0274 |
Bitewings - four radiographic images |
2,736 |
2,542 |
$113K |
| D1351 |
Sealant - per tooth |
3,040 |
800 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,532 |
1,376 |
$84K |
| D0330 |
Panoramic radiographic image |
1,007 |
938 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
556 |
324 |
$55K |
| D0272 |
Bitewings - two radiographic images |
1,262 |
1,208 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
270 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
1,500 |
1,430 |
$26K |
| D9310 |
|
697 |
623 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
180 |
103 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,021 |
909 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
523 |
489 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
140 |
131 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
12 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
21 |
15 |
$4K |
| D0470 |
|
25 |
25 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
78 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$2K |
| D8660 |
|
88 |
87 |
$931.56 |