| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,497 |
3,493 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
4,248 |
4,241 |
$90K |
| D8670 |
Periodic orthodontic treatment visit |
275 |
273 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
4,161 |
4,147 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
616 |
416 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,818 |
3,811 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,208 |
1,207 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,563 |
2,559 |
$28K |
| D1110 |
Prophylaxis - adult |
515 |
514 |
$19K |
| D1351 |
Sealant - per tooth |
408 |
151 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,181 |
1,181 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
602 |
600 |
$10K |
| D0340 |
|
171 |
171 |
$6K |
| D0274 |
Bitewings - four radiographic images |
305 |
305 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
52 |
$5K |
| D8660 |
|
166 |
166 |
$5K |
| D0350 |
|
404 |
404 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
120 |
77 |
$4K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
39 |
$2K |
| D9310 |
|
33 |
33 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$863.79 |
| D0140 |
Limited oral evaluation - problem focused |
61 |
61 |
$679.44 |
| D1330 |
|
12 |
12 |
$0.00 |