| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,913 |
11,678 |
$604K |
| D1206 |
Topical application of fluoride varnish |
13,534 |
13,188 |
$353K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,738 |
624 |
$337K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,923 |
1,661 |
$317K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,176 |
5,022 |
$294K |
| D0120 |
Periodic oral evaluation - established patient |
8,524 |
8,390 |
$251K |
| D1351 |
Sealant - per tooth |
4,302 |
1,254 |
$174K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,851 |
1,058 |
$166K |
| D7240 |
Removal of impacted tooth - completely bony |
451 |
152 |
$154K |
| D8670 |
Periodic orthodontic treatment visit |
489 |
466 |
$128K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,082 |
511 |
$109K |
| D0272 |
Bitewings - two radiographic images |
3,666 |
3,561 |
$109K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
738 |
224 |
$104K |
| D0140 |
Limited oral evaluation - problem focused |
2,388 |
2,288 |
$102K |
| D0274 |
Bitewings - four radiographic images |
2,079 |
2,032 |
$89K |
| D1110 |
Prophylaxis - adult |
1,347 |
1,310 |
$86K |
| D0330 |
Panoramic radiographic image |
1,020 |
980 |
$63K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,319 |
1,997 |
$48K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
476 |
230 |
$46K |
| D9310 |
|
775 |
689 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
1,906 |
1,761 |
$35K |
| D9222 |
|
235 |
230 |
$23K |
| D7230 |
|
78 |
49 |
$20K |
| D1354 |
|
1,057 |
348 |
$15K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
12 |
12 |
$14K |
| D8660 |
|
193 |
136 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
759 |
301 |
$8K |
| D9243 |
|
96 |
51 |
$8K |
| D9239 |
|
55 |
51 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
42 |
$2K |
| D9420 |
|
39 |
38 |
$1K |
| D0180 |
|
14 |
14 |
$638.00 |
| D0240 |
|
51 |
37 |
$338.00 |