| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,659 |
16,340 |
$849K |
| D1206 |
Topical application of fluoride varnish |
19,719 |
19,349 |
$514K |
| D0120 |
Periodic oral evaluation - established patient |
17,048 |
16,710 |
$495K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,575 |
1,825 |
$412K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,205 |
364 |
$230K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,303 |
1,198 |
$210K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,039 |
1,066 |
$204K |
| D1110 |
Prophylaxis - adult |
2,785 |
2,742 |
$192K |
| D0274 |
Bitewings - four radiographic images |
4,090 |
4,024 |
$178K |
| D0272 |
Bitewings - two radiographic images |
4,872 |
4,767 |
$144K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,574 |
754 |
$143K |
| D1351 |
Sealant - per tooth |
2,858 |
952 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,574 |
1,550 |
$92K |
| D0220 |
Intraoral - periapical first radiographic image |
4,479 |
4,347 |
$86K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
862 |
261 |
$84K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,573 |
2,467 |
$78K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
343 |
242 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,071 |
1,866 |
$42K |
| D2160 |
|
230 |
136 |
$24K |
| D0330 |
Panoramic radiographic image |
185 |
182 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
62 |
$3K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
22 |
12 |
$2K |
| D0240 |
|
69 |
36 |
$1K |
| D9222 |
|
12 |
12 |
$1K |
| D9110 |
|
12 |
12 |
$900.00 |
| D1999 |
|
459 |
443 |
$0.00 |