| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,434 |
3,407 |
$113K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,755 |
4,713 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,409 |
3,373 |
$68K |
| D1110 |
Prophylaxis - adult |
1,083 |
1,078 |
$50K |
| D1351 |
Sealant - per tooth |
1,285 |
404 |
$40K |
| D8670 |
Periodic orthodontic treatment visit |
91 |
91 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,184 |
1,182 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,615 |
1,596 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
329 |
157 |
$29K |
| D9920 |
|
422 |
389 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,961 |
1,934 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,837 |
1,798 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
161 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
520 |
462 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
93 |
58 |
$12K |
| D0274 |
Bitewings - four radiographic images |
386 |
382 |
$11K |
| D0240 |
|
831 |
397 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
225 |
175 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
30 |
$4K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$943.54 |
| D3120 |
|
21 |
13 |
$386.61 |
| D1354 |
|
30 |
12 |
$360.00 |