| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
29,004 |
28,594 |
$845K |
| D0120 |
Periodic oral evaluation - established patient |
27,053 |
26,667 |
$511K |
| D1206 |
Topical application of fluoride varnish |
33,359 |
32,850 |
$482K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,435 |
1,452 |
$450K |
| D1354 |
|
22,325 |
8,167 |
$395K |
| D1351 |
Sealant - per tooth |
18,147 |
5,269 |
$319K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,649 |
1,624 |
$234K |
| D0272 |
Bitewings - two radiographic images |
13,854 |
13,642 |
$210K |
| D1110 |
Prophylaxis - adult |
5,565 |
5,458 |
$198K |
| D0330 |
Panoramic radiographic image |
3,487 |
3,430 |
$143K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,766 |
2,714 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,481 |
1,466 |
$114K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
2,050 |
411 |
$111K |
| D0220 |
Intraoral - periapical first radiographic image |
9,364 |
9,198 |
$87K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,732 |
4,588 |
$72K |
| D0274 |
Bitewings - four radiographic images |
2,786 |
2,722 |
$69K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,307 |
2,263 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
917 |
582 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,627 |
4,112 |
$39K |
| D9222 |
|
482 |
410 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
282 |
129 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
298 |
296 |
$5K |
| D1353 |
|
554 |
218 |
$21.00 |
| D1330 |
|
24,798 |
23,800 |
$2.00 |
| D0603 |
|
25,625 |
24,266 |
$0.00 |