| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,270 |
4,195 |
$185K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
76 |
69 |
$183K |
| D1206 |
Topical application of fluoride varnish |
4,751 |
4,664 |
$158K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,368 |
2,313 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,763 |
2,732 |
$67K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
805 |
273 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
955 |
537 |
$49K |
| D0272 |
Bitewings - two radiographic images |
2,818 |
2,768 |
$48K |
| D0330 |
Panoramic radiographic image |
1,543 |
1,237 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,194 |
2,181 |
$29K |
| D8660 |
|
723 |
637 |
$29K |
| D1351 |
Sealant - per tooth |
1,329 |
359 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,585 |
2,434 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
659 |
368 |
$26K |
| D0340 |
|
917 |
638 |
$24K |
| D1110 |
Prophylaxis - adult |
500 |
490 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
947 |
860 |
$17K |
| D0350 |
|
917 |
638 |
$12K |
| D0274 |
Bitewings - four radiographic images |
502 |
487 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
184 |
$11K |
| D9999 |
Unspecified adjunctive procedure, by report |
386 |
386 |
$11K |
| D0999 |
Unspecified diagnostic procedure, by report |
369 |
369 |
$11K |
| D9248 |
|
120 |
105 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
108 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
65 |
25 |
$3K |
| D0603 |
|
983 |
947 |
$3K |
| D0602 |
|
676 |
662 |
$2K |
| D0601 |
|
663 |
645 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$378.88 |