| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,543 |
4,543 |
$152K |
| D8670 |
Periodic orthodontic treatment visit |
354 |
354 |
$150K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
730 |
393 |
$100K |
| D1206 |
Topical application of fluoride varnish |
3,598 |
3,598 |
$75K |
| D9920 |
|
1,076 |
1,033 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
697 |
467 |
$62K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,765 |
1,662 |
$60K |
| D1351 |
Sealant - per tooth |
1,823 |
542 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
855 |
493 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,886 |
2,886 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
692 |
489 |
$51K |
| D1110 |
Prophylaxis - adult |
919 |
919 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,787 |
1,787 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,839 |
1,839 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
359 |
348 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
651 |
651 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
802 |
795 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,060 |
1,052 |
$12K |
| D3120 |
|
639 |
369 |
$12K |
| D8660 |
|
43 |
43 |
$8K |
| D0240 |
|
576 |
305 |
$7K |
| D2940 |
|
119 |
81 |
$5K |
| D2330 |
|
41 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
212 |
$3K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$3K |
| D9310 |
|
32 |
32 |
$3K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
61 |
61 |
$1K |