| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
31,567 |
31,045 |
$839K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,634 |
2,560 |
$822K |
| D1120 |
Prophylaxis - child |
27,361 |
27,055 |
$769K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,658 |
5,010 |
$720K |
| D1206 |
Topical application of fluoride varnish |
37,046 |
36,500 |
$613K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13,152 |
12,418 |
$590K |
| D1110 |
Prophylaxis - adult |
10,233 |
10,097 |
$401K |
| D1351 |
Sealant - per tooth |
13,865 |
3,908 |
$398K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,460 |
2,397 |
$289K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,938 |
2,348 |
$238K |
| D0272 |
Bitewings - two radiographic images |
11,630 |
11,470 |
$219K |
| D0330 |
Panoramic radiographic image |
3,764 |
3,701 |
$219K |
| D8670 |
Periodic orthodontic treatment visit |
2,199 |
2,170 |
$213K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,401 |
4,325 |
$202K |
| D0274 |
Bitewings - four radiographic images |
4,793 |
4,710 |
$157K |
| D0220 |
Intraoral - periapical first radiographic image |
7,354 |
7,159 |
$113K |
| D0140 |
Limited oral evaluation - problem focused |
2,966 |
2,888 |
$113K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,146 |
3,621 |
$81K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,293 |
1,273 |
$48K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
556 |
321 |
$47K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
26 |
24 |
$19K |
| D2330 |
|
119 |
79 |
$8K |
| D2934 |
|
29 |
13 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
30 |
$4K |
| D7111 |
|
50 |
41 |
$3K |
| D9420 |
|
12 |
12 |
$2K |
| D9995 |
|
19 |
18 |
$1K |
| D9440 |
|
15 |
15 |
$958.15 |
| D1354 |
|
122 |
45 |
$797.72 |