| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
28,694 |
28,524 |
$959K |
| D0145 |
Oral evaluation for a patient under three years of age |
6,042 |
5,991 |
$838K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,786 |
1,977 |
$774K |
| D0120 |
Periodic oral evaluation - established patient |
25,826 |
25,681 |
$670K |
| D1206 |
Topical application of fluoride varnish |
32,041 |
31,860 |
$476K |
| D0230 |
Intraoral - periapical each additional radiographic image |
41,140 |
31,159 |
$453K |
| D0220 |
Intraoral - periapical first radiographic image |
33,909 |
33,531 |
$389K |
| D0272 |
Bitewings - two radiographic images |
17,644 |
17,525 |
$374K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,976 |
1,736 |
$265K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,420 |
6,367 |
$218K |
| D9248 |
|
2,529 |
2,461 |
$202K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,876 |
1,841 |
$194K |
| D1110 |
Prophylaxis - adult |
3,342 |
3,321 |
$175K |
| D7240 |
Removal of impacted tooth - completely bony |
707 |
209 |
$171K |
| D0274 |
Bitewings - four radiographic images |
5,129 |
5,103 |
$154K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,293 |
3,172 |
$86K |
| D0140 |
Limited oral evaluation - problem focused |
1,792 |
1,774 |
$35K |
| D1351 |
Sealant - per tooth |
1,249 |
414 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
540 |
379 |
$32K |
| D0330 |
Panoramic radiographic image |
1,897 |
1,879 |
$31K |
| D2335 |
|
209 |
95 |
$29K |
| D9239 |
|
238 |
236 |
$19K |
| D9243 |
|
372 |
228 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
108 |
56 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$6K |
| D9610 |
|
202 |
201 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
25 |
$4K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
64 |
25 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
127 |
124 |
$2K |
| D9222 |
|
25 |
25 |
$1K |
| D7111 |
|
23 |
14 |
$765.24 |
| D0170 |
|
12 |
12 |
$198.48 |
| D0603 |
|
27,375 |
27,107 |
$0.00 |