| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,041 |
4,033 |
$122K |
| D8670 |
Periodic orthodontic treatment visit |
339 |
337 |
$119K |
| D1206 |
Topical application of fluoride varnish |
5,512 |
5,501 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
4,357 |
4,344 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,252 |
799 |
$78K |
| D1110 |
Prophylaxis - adult |
1,656 |
1,653 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,128 |
789 |
$57K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
720 |
275 |
$54K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
125 |
125 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
455 |
202 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
721 |
416 |
$46K |
| D0251 |
|
2,101 |
1,981 |
$33K |
| D1351 |
Sealant - per tooth |
1,305 |
316 |
$32K |
| D0330 |
Panoramic radiographic image |
523 |
523 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
953 |
952 |
$20K |
| D9222 |
|
125 |
125 |
$15K |
| D2933 |
|
68 |
27 |
$10K |
| D2331 |
|
124 |
78 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
107 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
65 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
393 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
160 |
$3K |
| D0240 |
|
117 |
113 |
$3K |
| D2330 |
|
23 |
15 |
$1K |
| D1330 |
|
99 |
99 |
$1K |
| D1310 |
|
99 |
99 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$729.69 |
| D8660 |
|
12 |
12 |
$420.00 |
| D0340 |
|
16 |
15 |
$256.80 |
| D9995 |
|
48 |
48 |
$0.00 |