| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
27,708 |
27,076 |
$714K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,233 |
1,339 |
$625K |
| D1120 |
Prophylaxis - child |
20,396 |
19,985 |
$557K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,844 |
1,650 |
$415K |
| D1110 |
Prophylaxis - adult |
10,616 |
10,278 |
$398K |
| D1206 |
Topical application of fluoride varnish |
24,643 |
24,004 |
$395K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,912 |
2,053 |
$272K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,771 |
5,476 |
$253K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,737 |
676 |
$219K |
| D0330 |
Panoramic radiographic image |
4,422 |
4,272 |
$200K |
| D2140 |
|
2,706 |
2,042 |
$196K |
| D0274 |
Bitewings - four radiographic images |
6,237 |
6,030 |
$190K |
| D0272 |
Bitewings - two radiographic images |
9,397 |
9,215 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,975 |
2,903 |
$131K |
| D1351 |
Sealant - per tooth |
4,075 |
1,161 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,356 |
727 |
$89K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,733 |
4,670 |
$79K |
| D0240 |
|
4,453 |
2,257 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
848 |
818 |
$30K |
| D0160 |
|
428 |
422 |
$28K |
| D9248 |
|
2,369 |
2,275 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,133 |
1,084 |
$16K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
227 |
81 |
$15K |
| D9610 |
|
232 |
227 |
$9K |
| D2160 |
|
81 |
62 |
$8K |
| D7240 |
Removal of impacted tooth - completely bony |
30 |
12 |
$6K |
| D2335 |
|
23 |
14 |
$3K |
| D9222 |
|
38 |
38 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
189 |
78 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D9612 |
|
12 |
12 |
$727.80 |
| D1354 |
|
149 |
30 |
$698.47 |