| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,742 |
7,742 |
$248K |
| D0120 |
Periodic oral evaluation - established patient |
7,787 |
7,787 |
$172K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,542 |
1,892 |
$166K |
| D8670 |
Periodic orthodontic treatment visit |
704 |
704 |
$148K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,169 |
607 |
$111K |
| D1110 |
Prophylaxis - adult |
2,260 |
2,260 |
$94K |
| D1206 |
Topical application of fluoride varnish |
3,523 |
3,523 |
$85K |
| D1351 |
Sealant - per tooth |
1,930 |
740 |
$82K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,647 |
5,647 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,350 |
2,350 |
$51K |
| D0272 |
Bitewings - two radiographic images |
3,466 |
3,466 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
4,081 |
4,039 |
$39K |
| D0340 |
|
876 |
876 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,467 |
1,467 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
418 |
349 |
$32K |
| D9310 |
|
766 |
766 |
$32K |
| D0330 |
Panoramic radiographic image |
762 |
762 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
512 |
442 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
482 |
375 |
$21K |
| D8660 |
|
551 |
551 |
$15K |
| D0350 |
|
949 |
949 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
744 |
724 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
928 |
672 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
24 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
62 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
15 |
$2K |
| D1354 |
|
36 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$966.27 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$339.43 |