| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,603 |
8,223 |
$366K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
127 |
112 |
$297K |
| D1351 |
Sealant - per tooth |
10,855 |
2,202 |
$230K |
| D1206 |
Topical application of fluoride varnish |
6,916 |
6,615 |
$226K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,109 |
2,025 |
$157K |
| D0120 |
Periodic oral evaluation - established patient |
6,285 |
6,037 |
$154K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,924 |
8,805 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,694 |
3,511 |
$115K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,645 |
644 |
$106K |
| D0240 |
|
5,090 |
4,082 |
$104K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,612 |
1,291 |
$101K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,221 |
4,683 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,299 |
1,477 |
$87K |
| D1110 |
Prophylaxis - adult |
1,684 |
1,619 |
$71K |
| D8660 |
|
1,517 |
1,432 |
$68K |
| D0272 |
Bitewings - two radiographic images |
3,924 |
3,746 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,862 |
2,726 |
$64K |
| D0330 |
Panoramic radiographic image |
2,278 |
2,094 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
4,911 |
4,598 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
1,325 |
1,279 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,276 |
4,106 |
$42K |
| D9222 |
|
79 |
59 |
$24K |
| D1353 |
|
1,812 |
419 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
414 |
407 |
$23K |
| D3120 |
|
1,532 |
759 |
$21K |
| D9999 |
Unspecified adjunctive procedure, by report |
369 |
369 |
$18K |
| D0170 |
|
1,010 |
916 |
$16K |
| D0999 |
Unspecified diagnostic procedure, by report |
451 |
451 |
$14K |
| D0603 |
|
5,328 |
5,075 |
$10K |
| D1354 |
|
710 |
271 |
$8K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
281 |
59 |
$7K |
| D0340 |
|
335 |
258 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
108 |
50 |
$5K |
| D0350 |
|
407 |
322 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
104 |
104 |
$2K |
| D9310 |
|
41 |
40 |
$2K |
| D9410 |
|
13 |
12 |
$738.00 |
| D0601 |
|
406 |
363 |
$473.00 |
| D0602 |
|
328 |
316 |
$354.75 |
| D9630 |
|
61 |
53 |
$90.00 |
| D9440 |
|
19 |
19 |
$60.00 |
| D9311 |
|
19 |
19 |
$36.90 |
| D0270 |
|
29 |
29 |
$12.38 |
| D9986 |
|
1,183 |
1,100 |
$0.00 |
| D0472 |
|
126 |
122 |
$0.00 |