| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,079 |
9,923 |
$349K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,131 |
209 |
$214K |
| D1206 |
Topical application of fluoride varnish |
10,773 |
10,594 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
5,124 |
5,055 |
$146K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,312 |
800 |
$121K |
| D0272 |
Bitewings - two radiographic images |
4,280 |
4,196 |
$109K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,197 |
2,100 |
$94K |
| D0140 |
Limited oral evaluation - problem focused |
1,551 |
1,508 |
$75K |
| D7140 |
Extraction, erupted tooth or exposed root |
629 |
233 |
$60K |
| D1351 |
Sealant - per tooth |
2,320 |
921 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
579 |
351 |
$47K |
| D0240 |
|
1,605 |
928 |
$34K |
| D1354 |
|
1,642 |
1,594 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,249 |
1,203 |
$20K |
| D0274 |
Bitewings - four radiographic images |
405 |
402 |
$18K |
| D1110 |
Prophylaxis - adult |
216 |
216 |
$12K |
| D0330 |
Panoramic radiographic image |
168 |
162 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
143 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
82 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
91 |
86 |
$2K |
| D1999 |
|
376 |
358 |
$32.00 |
| D0602 |
|
1,209 |
1,195 |
$1.48 |
| D0601 |
|
519 |
513 |
$1.34 |
| D0603 |
|
1,302 |
1,282 |
$1.13 |
| D1330 |
|
7,151 |
7,063 |
$0.12 |
| D1310 |
|
2,573 |
2,538 |
$0.06 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
30 |
27 |
$0.00 |
| D0191 |
|
14 |
13 |
$0.00 |