| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,371 |
11,267 |
$505K |
| D8670 |
Periodic orthodontic treatment visit |
6,433 |
5,726 |
$474K |
| D0120 |
Periodic oral evaluation - established patient |
11,370 |
11,269 |
$342K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,211 |
1,631 |
$278K |
| D1351 |
Sealant - per tooth |
7,908 |
2,003 |
$275K |
| D1206 |
Topical application of fluoride varnish |
8,662 |
8,590 |
$215K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,288 |
5,231 |
$125K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
748 |
442 |
$114K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,059 |
834 |
$105K |
| D1110 |
Prophylaxis - adult |
1,532 |
1,522 |
$94K |
| D0274 |
Bitewings - four radiographic images |
4,057 |
4,018 |
$93K |
| D0272 |
Bitewings - two radiographic images |
5,654 |
5,608 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,629 |
1,620 |
$86K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,590 |
4,161 |
$85K |
| D0140 |
Limited oral evaluation - problem focused |
931 |
920 |
$41K |
| D1330 |
|
6,005 |
5,951 |
$38K |
| D9310 |
|
741 |
737 |
$35K |
| D0330 |
Panoramic radiographic image |
681 |
677 |
$29K |
| D8660 |
|
170 |
168 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
228 |
138 |
$23K |
| D3120 |
|
430 |
229 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
478 |
470 |
$5K |
| D0240 |
|
139 |
137 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$120.00 |