| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,518 |
15,490 |
$801K |
| D0120 |
Periodic oral evaluation - established patient |
21,057 |
20,987 |
$601K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,695 |
3,690 |
$583K |
| D1110 |
Prophylaxis - adult |
9,095 |
9,051 |
$582K |
| D8670 |
Periodic orthodontic treatment visit |
2,320 |
2,287 |
$573K |
| D1206 |
Topical application of fluoride varnish |
20,773 |
20,709 |
$545K |
| D1351 |
Sealant - per tooth |
13,085 |
4,848 |
$528K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,178 |
1,232 |
$437K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,733 |
3,271 |
$390K |
| D0274 |
Bitewings - four radiographic images |
8,969 |
8,943 |
$370K |
| D0272 |
Bitewings - two radiographic images |
8,032 |
8,010 |
$242K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
178 |
177 |
$204K |
| D0330 |
Panoramic radiographic image |
4,708 |
4,673 |
$193K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,344 |
3,295 |
$147K |
| D0140 |
Limited oral evaluation - problem focused |
2,705 |
2,656 |
$113K |
| D0220 |
Intraoral - periapical first radiographic image |
6,093 |
5,959 |
$110K |
| D2740 |
Crown - porcelain/ceramic |
152 |
97 |
$108K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
647 |
401 |
$93K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
695 |
558 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
786 |
519 |
$75K |
| D7240 |
Removal of impacted tooth - completely bony |
196 |
69 |
$68K |
| D8690 |
|
462 |
462 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,404 |
2,912 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
778 |
764 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,402 |
2,133 |
$49K |
| D7111 |
|
512 |
332 |
$40K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
210 |
166 |
$19K |
| D2332 |
|
158 |
109 |
$18K |
| D8680 |
|
209 |
195 |
$17K |
| D0270 |
|
785 |
767 |
$10K |
| D2330 |
|
113 |
65 |
$9K |
| D2335 |
|
38 |
26 |
$6K |
| D2140 |
|
60 |
50 |
$4K |
| D8999 |
|
58 |
52 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$465.00 |
| D1999 |
|
5,164 |
4,350 |
$0.00 |
| D9310 |
|
28 |
28 |
$0.00 |