| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,833 |
9,829 |
$369K |
| D0120 |
Periodic oral evaluation - established patient |
11,660 |
11,656 |
$280K |
| D1351 |
Sealant - per tooth |
3,928 |
1,314 |
$160K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,009 |
12,006 |
$150K |
| D1110 |
Prophylaxis - adult |
2,083 |
2,082 |
$95K |
| D0272 |
Bitewings - two radiographic images |
5,283 |
5,283 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
6,195 |
6,162 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,183 |
922 |
$50K |
| D0330 |
Panoramic radiographic image |
1,506 |
1,506 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
761 |
440 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,065 |
4,062 |
$22K |
| D0274 |
Bitewings - four radiographic images |
817 |
817 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
89 |
55 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
352 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
650 |
643 |
$8K |
| D8670 |
Periodic orthodontic treatment visit |
25 |
25 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
60 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
26 |
$3K |
| D8660 |
|
68 |
68 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
15 |
$2K |
| D0340 |
|
29 |
29 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
45 |
45 |
$1K |
| D1206 |
Topical application of fluoride varnish |
34 |
34 |
$790.32 |
| D0601 |
|
474 |
474 |
$474.00 |
| D0350 |
|
41 |
41 |
$464.39 |
| D0602 |
|
78 |
78 |
$78.00 |
| D0603 |
|
13 |
13 |
$13.00 |