| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,726 |
12,634 |
$737K |
| D0120 |
Periodic oral evaluation - established patient |
11,867 |
11,795 |
$680K |
| D1206 |
Topical application of fluoride varnish |
13,193 |
13,091 |
$596K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,544 |
1,260 |
$343K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,468 |
651 |
$271K |
| D1351 |
Sealant - per tooth |
4,009 |
1,258 |
$201K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
944 |
358 |
$192K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,478 |
755 |
$183K |
| D0272 |
Bitewings - two radiographic images |
3,864 |
3,840 |
$181K |
| D0140 |
Limited oral evaluation - problem focused |
2,775 |
2,717 |
$166K |
| D0274 |
Bitewings - four radiographic images |
1,729 |
1,716 |
$125K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,305 |
3,964 |
$114K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,040 |
659 |
$100K |
| D1110 |
Prophylaxis - adult |
939 |
937 |
$94K |
| D0330 |
Panoramic radiographic image |
748 |
739 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,163 |
1,149 |
$74K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
638 |
434 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
1,450 |
1,421 |
$40K |
| D7230 |
|
65 |
36 |
$26K |
| D2140 |
|
288 |
214 |
$20K |
| D0240 |
|
353 |
185 |
$18K |
| D7240 |
Removal of impacted tooth - completely bony |
33 |
14 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
389 |
176 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
97 |
64 |
$8K |
| D9310 |
|
84 |
81 |
$5K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
24 |
14 |
$3K |
| D9222 |
|
27 |
26 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$3K |
| D1354 |
|
102 |
42 |
$3K |
| D9610 |
|
27 |
26 |
$902.23 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$782.08 |
| D1999 |
|
32 |
31 |
$0.00 |