| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,471 |
2,456 |
$91K |
| D1351 |
Sealant - per tooth |
430 |
380 |
$91K |
| D1120 |
Prophylaxis - child |
2,123 |
2,112 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
571 |
533 |
$85K |
| D1206 |
Topical application of fluoride varnish |
3,080 |
3,052 |
$78K |
| D1110 |
Prophylaxis - adult |
1,123 |
1,117 |
$68K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
235 |
212 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,311 |
1,299 |
$59K |
| D0272 |
Bitewings - two radiographic images |
1,487 |
1,470 |
$51K |
| D9248 |
|
171 |
163 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,078 |
1,064 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,668 |
1,629 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
623 |
621 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
220 |
194 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
554 |
534 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
41 |
$35K |
| D0603 |
|
2,900 |
2,874 |
$28K |
| D8670 |
Periodic orthodontic treatment visit |
79 |
79 |
$28K |
| D1320 |
|
1,863 |
1,846 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,024 |
2,000 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
192 |
$22K |
| D1310 |
|
3,657 |
3,626 |
$18K |
| D1330 |
|
3,663 |
3,632 |
$18K |
| D0330 |
Panoramic radiographic image |
427 |
425 |
$18K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
13 |
13 |
$12K |
| D4346 |
|
192 |
191 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
73 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
41 |
$9K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
13 |
13 |
$5K |
| D8660 |
|
75 |
75 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D9222 |
|
12 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
48 |
48 |
$2K |
| D1354 |
|
23 |
19 |
$200.00 |
| D0340 |
|
74 |
74 |
$109.22 |