| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
20,673 |
20,576 |
$930K |
| D0120 |
Periodic oral evaluation - established patient |
36,332 |
36,147 |
$859K |
| D1206 |
Topical application of fluoride varnish |
37,184 |
36,997 |
$695K |
| D1120 |
Prophylaxis - child |
15,644 |
15,569 |
$524K |
| D0274 |
Bitewings - four radiographic images |
12,948 |
12,857 |
$387K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,746 |
11,741 |
$298K |
| D1351 |
Sealant - per tooth |
8,075 |
3,531 |
$289K |
| D7240 |
Removal of impacted tooth - completely bony |
881 |
283 |
$241K |
| D0272 |
Bitewings - two radiographic images |
8,663 |
8,581 |
$182K |
| D0220 |
Intraoral - periapical first radiographic image |
13,966 |
13,934 |
$180K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,489 |
1,024 |
$170K |
| D2140 |
|
1,830 |
1,367 |
$162K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,111 |
294 |
$138K |
| D0330 |
Panoramic radiographic image |
2,685 |
2,673 |
$136K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,180 |
862 |
$126K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,109 |
2,026 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
475 |
350 |
$64K |
| D9243 |
|
197 |
197 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
1,464 |
1,461 |
$44K |
| D1353 |
|
900 |
607 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
670 |
670 |
$28K |
| D9239 |
|
198 |
198 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
618 |
614 |
$21K |
| D9310 |
|
443 |
443 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
357 |
357 |
$11K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
26 |
25 |
$10K |
| D4346 |
|
200 |
199 |
$9K |
| D2160 |
|
50 |
39 |
$8K |
| D2934 |
|
38 |
12 |
$6K |
| D7230 |
|
27 |
13 |
$6K |
| D8660 |
|
34 |
34 |
$5K |
| D0240 |
|
100 |
98 |
$3K |
| D0350 |
|
96 |
86 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
24 |
$3K |
| D9222 |
|
25 |
25 |
$2K |
| D7111 |
|
46 |
37 |
$2K |
| D0340 |
|
36 |
36 |
$2K |
| D9219 |
|
25 |
25 |
$987.75 |