| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,099 |
5,025 |
$328K |
| D1206 |
Topical application of fluoride varnish |
8,311 |
8,186 |
$210K |
| D1351 |
Sealant - per tooth |
5,759 |
669 |
$210K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,441 |
3,372 |
$188K |
| D8670 |
Periodic orthodontic treatment visit |
2,049 |
1,997 |
$152K |
| D0120 |
Periodic oral evaluation - established patient |
4,431 |
4,381 |
$136K |
| D0330 |
Panoramic radiographic image |
2,969 |
2,909 |
$132K |
| D1120 |
Prophylaxis - child |
2,603 |
2,570 |
$118K |
| D0274 |
Bitewings - four radiographic images |
4,711 |
4,634 |
$110K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
638 |
349 |
$86K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
65 |
65 |
$67K |
| D8090 |
|
65 |
65 |
$58K |
| D8660 |
|
369 |
363 |
$54K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
289 |
214 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
1,018 |
989 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
117 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,465 |
1,413 |
$17K |
| D1330 |
|
2,411 |
2,371 |
$16K |
| D0272 |
Bitewings - two radiographic images |
802 |
791 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
523 |
518 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
132 |
$3K |