| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
19,470 |
19,339 |
$1.02M |
| D1208 |
Topical application of fluoride, excluding varnish |
22,987 |
22,824 |
$685K |
| D0274 |
Bitewings - four radiographic images |
14,182 |
14,072 |
$625K |
| D0120 |
Periodic oral evaluation - established patient |
20,173 |
20,049 |
$603K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,018 |
2,553 |
$468K |
| D1351 |
Sealant - per tooth |
11,213 |
3,288 |
$467K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,823 |
874 |
$356K |
| D1110 |
Prophylaxis - adult |
3,532 |
3,506 |
$246K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,174 |
1,153 |
$219K |
| D0220 |
Intraoral - periapical first radiographic image |
10,286 |
10,109 |
$208K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,270 |
1,247 |
$207K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,356 |
3,316 |
$196K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,643 |
213 |
$159K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,499 |
8,549 |
$149K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,591 |
1,144 |
$146K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,031 |
5,763 |
$124K |
| D0140 |
Limited oral evaluation - problem focused |
1,733 |
1,704 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
504 |
385 |
$63K |
| D0330 |
Panoramic radiographic image |
684 |
678 |
$63K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
593 |
276 |
$61K |
| D0272 |
Bitewings - two radiographic images |
1,461 |
1,450 |
$45K |
| D3120 |
|
953 |
620 |
$37K |
| D2160 |
|
165 |
112 |
$18K |
| D9222 |
|
172 |
162 |
$17K |
| D1354 |
|
418 |
134 |
$6K |
| D2330 |
|
36 |
25 |
$3K |
| D2332 |
|
16 |
13 |
$2K |
| D0240 |
|
24 |
22 |
$270.00 |
| D9215 |
|
5,153 |
4,941 |
$0.00 |
| D1330 |
|
22,965 |
22,756 |
$0.00 |