| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,380 |
15,950 |
$729K |
| D1206 |
Topical application of fluoride varnish |
19,838 |
19,379 |
$708K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,330 |
1,597 |
$353K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,467 |
10,249 |
$331K |
| D0272 |
Bitewings - two radiographic images |
15,917 |
15,573 |
$277K |
| D0230 |
Intraoral - periapical each additional radiographic image |
49,788 |
22,019 |
$264K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
161 |
96 |
$250K |
| D0120 |
Periodic oral evaluation - established patient |
9,412 |
9,169 |
$238K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,536 |
2,841 |
$231K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,304 |
2,206 |
$166K |
| D0330 |
Panoramic radiographic image |
4,149 |
3,942 |
$136K |
| D0220 |
Intraoral - periapical first radiographic image |
11,175 |
10,805 |
$130K |
| D1110 |
Prophylaxis - adult |
2,804 |
2,745 |
$120K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,311 |
5,809 |
$112K |
| D9999 |
Unspecified adjunctive procedure, by report |
2,259 |
2,259 |
$106K |
| D1351 |
Sealant - per tooth |
4,893 |
1,517 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,158 |
1,509 |
$84K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,208 |
563 |
$54K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
605 |
210 |
$45K |
| D8660 |
|
881 |
775 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
1,125 |
1,101 |
$36K |
| D0340 |
|
854 |
757 |
$31K |
| D9310 |
|
489 |
467 |
$21K |
| D0999 |
Unspecified diagnostic procedure, by report |
682 |
682 |
$20K |
| D0350 |
|
855 |
754 |
$14K |
| D9222 |
|
242 |
209 |
$11K |
| D9420 |
|
240 |
231 |
$9K |
| D0603 |
|
5,387 |
4,806 |
$8K |
| D0601 |
|
3,162 |
2,939 |
$6K |
| D0602 |
|
5,104 |
4,698 |
$5K |
| D0240 |
|
301 |
142 |
$3K |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$3K |
| D1999 |
|
235 |
230 |
$2K |
| D4355 |
|
30 |
30 |
$1K |
| D1354 |
|
90 |
38 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
43 |
$820.00 |
| D0170 |
|
37 |
37 |
$571.64 |
| D3120 |
|
23 |
13 |
$298.00 |
| D9212 |
|
15 |
15 |
$153.75 |
| D0270 |
|
14 |
12 |
$110.70 |
| D9986 |
|
2,305 |
2,250 |
$0.00 |
| D9987 |
|
640 |
625 |
$0.00 |