| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,937 |
4,910 |
$254K |
| D1206 |
Topical application of fluoride varnish |
5,895 |
5,859 |
$218K |
| D0120 |
Periodic oral evaluation - established patient |
3,544 |
3,530 |
$172K |
| D1310 |
|
3,605 |
3,556 |
$160K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,130 |
2,115 |
$133K |
| D1351 |
Sealant - per tooth |
3,393 |
1,118 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,735 |
1,032 |
$114K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,051 |
4,513 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,531 |
708 |
$87K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
113 |
92 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
616 |
262 |
$72K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,223 |
1,212 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,710 |
1,431 |
$67K |
| D9999 |
Unspecified adjunctive procedure, by report |
642 |
595 |
$64K |
| D1110 |
Prophylaxis - adult |
696 |
694 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
4,426 |
4,362 |
$52K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
364 |
158 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
618 |
484 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,629 |
2,622 |
$31K |
| D0330 |
Panoramic radiographic image |
1,012 |
1,005 |
$30K |
| D9430 |
|
877 |
844 |
$28K |
| D0603 |
|
1,998 |
1,976 |
$27K |
| D0602 |
|
1,711 |
1,686 |
$24K |
| D0274 |
Bitewings - four radiographic images |
744 |
743 |
$16K |
| D9222 |
|
92 |
92 |
$15K |
| D1354 |
|
993 |
279 |
$8K |
| D1510 |
|
36 |
25 |
$7K |
| D0350 |
|
700 |
420 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
61 |
$6K |
| D9610 |
|
86 |
26 |
$2K |
| D0601 |
|
29 |
28 |
$234.00 |
| D9993 |
|
214 |
212 |
$0.00 |