| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,820 |
16,558 |
$401K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,885 |
2,281 |
$225K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,496 |
924 |
$198K |
| D1206 |
Topical application of fluoride varnish |
9,401 |
9,166 |
$188K |
| D0120 |
Periodic oral evaluation - established patient |
8,990 |
8,802 |
$176K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
8,480 |
8,371 |
$162K |
| D1354 |
|
8,808 |
2,998 |
$156K |
| D0272 |
Bitewings - two radiographic images |
8,294 |
8,159 |
$108K |
| D1110 |
Prophylaxis - adult |
3,119 |
3,057 |
$98K |
| D1351 |
Sealant - per tooth |
5,517 |
1,534 |
$96K |
| D0330 |
Panoramic radiographic image |
1,550 |
1,466 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,686 |
839 |
$77K |
| D0274 |
Bitewings - four radiographic images |
2,762 |
2,714 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
4,718 |
4,565 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
918 |
474 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,639 |
9,538 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,557 |
2,504 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,892 |
1,876 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,761 |
2,146 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
729 |
712 |
$12K |
| D9248 |
|
357 |
356 |
$11K |
| D1355 |
|
130 |
41 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
144 |
60 |
$2K |
| D0601 |
|
1,318 |
1,304 |
$0.00 |
| D0603 |
|
12,918 |
11,549 |
$0.00 |
| D0602 |
|
529 |
525 |
$0.00 |
| D9222 |
|
12 |
12 |
$0.00 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
12 |
12 |
$0.00 |