| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,713 |
11,569 |
$512K |
| D1351 |
Sealant - per tooth |
12,817 |
3,616 |
$443K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,289 |
1,954 |
$400K |
| D1206 |
Topical application of fluoride varnish |
14,162 |
13,985 |
$351K |
| D0120 |
Periodic oral evaluation - established patient |
11,525 |
11,387 |
$340K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,401 |
689 |
$216K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,256 |
1,504 |
$214K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,689 |
1,033 |
$188K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,792 |
4,359 |
$87K |
| D1110 |
Prophylaxis - adult |
1,396 |
1,380 |
$85K |
| D0272 |
Bitewings - two radiographic images |
5,384 |
5,320 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,315 |
1,300 |
$69K |
| D8670 |
Periodic orthodontic treatment visit |
855 |
813 |
$64K |
| D0330 |
Panoramic radiographic image |
1,430 |
1,426 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
1,250 |
1,203 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
3,598 |
3,481 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,366 |
1,353 |
$31K |
| D1330 |
|
4,560 |
4,504 |
$27K |
| D3120 |
|
611 |
385 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,863 |
1,818 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
216 |
216 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
12 |
$1K |
| D0240 |
|
31 |
31 |
$549.00 |
| D9420 |
|
17 |
17 |
$255.00 |