| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
13,484 |
12,808 |
$644K |
| D1120 |
Prophylaxis - child |
12,575 |
11,980 |
$642K |
| D0120 |
Periodic oral evaluation - established patient |
12,846 |
12,184 |
$382K |
| D1351 |
Sealant - per tooth |
11,656 |
3,007 |
$240K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,885 |
942 |
$233K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,998 |
1,736 |
$188K |
| D0272 |
Bitewings - two radiographic images |
6,109 |
5,758 |
$112K |
| D0220 |
Intraoral - periapical first radiographic image |
7,440 |
6,945 |
$106K |
| D1110 |
Prophylaxis - adult |
2,171 |
2,026 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,808 |
915 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,139 |
7,442 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,620 |
922 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,610 |
2,375 |
$44K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
791 |
192 |
$39K |
| D9248 |
|
461 |
425 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,792 |
1,669 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
645 |
323 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,247 |
1,169 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
514 |
326 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
948 |
908 |
$29K |
| D0330 |
Panoramic radiographic image |
468 |
447 |
$17K |
| D9310 |
|
312 |
288 |
$17K |
| D9222 |
|
229 |
204 |
$16K |
| D1354 |
|
1,304 |
405 |
$11K |
| D0999 |
Unspecified diagnostic procedure, by report |
366 |
366 |
$11K |
| D2330 |
|
149 |
68 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
337 |
337 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
165 |
157 |
$3K |
| D3120 |
|
103 |
63 |
$2K |
| D0270 |
|
144 |
139 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
108 |
$890.88 |
| D0603 |
|
282 |
274 |
$232.00 |
| D1330 |
|
588 |
550 |
$0.00 |