| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,470 |
4,409 |
$148K |
| D8670 |
Periodic orthodontic treatment visit |
350 |
347 |
$140K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,371 |
720 |
$119K |
| D1206 |
Topical application of fluoride varnish |
5,589 |
5,485 |
$115K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
996 |
328 |
$115K |
| D9920 |
|
1,659 |
1,604 |
$114K |
| D9310 |
|
1,479 |
1,327 |
$108K |
| D7240 |
Removal of impacted tooth - completely bony |
387 |
121 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,860 |
3,804 |
$76K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,121 |
364 |
$67K |
| D1110 |
Prophylaxis - adult |
926 |
912 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
585 |
351 |
$43K |
| D1351 |
Sealant - per tooth |
1,340 |
431 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,339 |
1,317 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,222 |
1,250 |
$35K |
| D0330 |
Panoramic radiographic image |
768 |
686 |
$35K |
| D0240 |
|
2,851 |
1,515 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
379 |
219 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
648 |
584 |
$25K |
| D9222 |
|
387 |
359 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,151 |
1,139 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,834 |
1,812 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
595 |
565 |
$20K |
| D0274 |
Bitewings - four radiographic images |
723 |
713 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
99 |
42 |
$13K |
| D8660 |
|
52 |
52 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
86 |
24 |
$7K |
| D9610 |
|
327 |
302 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
173 |
$4K |
| D2330 |
|
58 |
24 |
$4K |
| D7230 |
|
21 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
77 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$1K |
| D9630 |
|
18 |
17 |
$337.79 |