| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
13,518 |
13,469 |
$748K |
| D1120 |
Prophylaxis - child |
16,364 |
16,302 |
$617K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
781 |
392 |
$542K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,739 |
2,723 |
$309K |
| D9221 |
|
462 |
269 |
$300K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,430 |
990 |
$281K |
| D1351 |
Sealant - per tooth |
9,328 |
2,715 |
$262K |
| D9420 |
|
1,057 |
1,020 |
$241K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,491 |
3,474 |
$214K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,444 |
1,547 |
$194K |
| D1206 |
Topical application of fluoride varnish |
12,925 |
12,876 |
$167K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,435 |
1,658 |
$129K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,157 |
2,046 |
$84K |
| D1310 |
|
1,946 |
1,938 |
$82K |
| D9430 |
|
2,420 |
2,342 |
$75K |
| D2330 |
|
1,012 |
512 |
$74K |
| D0272 |
Bitewings - two radiographic images |
6,318 |
6,286 |
$72K |
| D9220 |
|
269 |
269 |
$60K |
| D9993 |
|
1,026 |
1,021 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,009 |
4,783 |
$49K |
| D0145 |
Oral evaluation for a patient under three years of age |
866 |
859 |
$48K |
| D9222 |
|
382 |
380 |
$46K |
| D0274 |
Bitewings - four radiographic images |
2,084 |
2,078 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,039 |
3,025 |
$39K |
| D2940 |
|
737 |
426 |
$39K |
| D9610 |
|
545 |
379 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,632 |
1,600 |
$19K |
| D9248 |
|
532 |
512 |
$18K |
| D0603 |
|
1,276 |
1,271 |
$17K |
| D1510 |
|
66 |
51 |
$10K |
| D0160 |
|
83 |
83 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
51 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
63 |
$6K |
| D0240 |
|
118 |
73 |
$1K |
| D2331 |
|
15 |
12 |
$1K |
| D0602 |
|
103 |
102 |
$855.00 |
| D1354 |
|
102 |
33 |
$768.00 |
| D9995 |
|
190 |
179 |
$382.32 |
| D0270 |
|
74 |
73 |
$365.00 |
| D0601 |
|
12 |
12 |
$165.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
19 |
19 |
$120.48 |
| D0350 |
|
19 |
15 |
$91.00 |
| D9996 |
|
12 |
12 |
$0.00 |