| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,224 |
13,086 |
$451K |
| D1206 |
Topical application of fluoride varnish |
20,953 |
20,742 |
$405K |
| D7240 |
Removal of impacted tooth - completely bony |
1,421 |
429 |
$392K |
| D0120 |
Periodic oral evaluation - established patient |
16,365 |
16,186 |
$391K |
| D1110 |
Prophylaxis - adult |
7,611 |
7,543 |
$347K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,016 |
3,989 |
$163K |
| D0330 |
Panoramic radiographic image |
2,904 |
2,889 |
$151K |
| D0272 |
Bitewings - two radiographic images |
6,078 |
6,003 |
$128K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,830 |
2,751 |
$88K |
| D0274 |
Bitewings - four radiographic images |
2,950 |
2,939 |
$88K |
| D8660 |
|
422 |
416 |
$57K |
| D9243 |
|
270 |
268 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
169 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
424 |
225 |
$42K |
| D8670 |
Periodic orthodontic treatment visit |
298 |
298 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
917 |
911 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
295 |
160 |
$30K |
| D9239 |
|
269 |
269 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
137 |
$27K |
| D0340 |
|
417 |
411 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
172 |
84 |
$21K |
| D0350 |
|
403 |
395 |
$12K |
| D2140 |
|
106 |
60 |
$9K |
| D1351 |
Sealant - per tooth |
227 |
68 |
$8K |
| D0240 |
|
176 |
176 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
371 |
$5K |
| D9219 |
|
39 |
39 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
36 |
36 |
$1K |