| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,975 |
8,907 |
$434K |
| D0120 |
Periodic oral evaluation - established patient |
4,519 |
4,487 |
$332K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,610 |
2,480 |
$294K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,790 |
508 |
$202K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,427 |
1,763 |
$178K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,616 |
2,609 |
$176K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,858 |
8,783 |
$170K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39,935 |
7,597 |
$163K |
| D1310 |
|
3,604 |
3,554 |
$161K |
| D1351 |
Sealant - per tooth |
4,323 |
1,604 |
$146K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,850 |
2,447 |
$112K |
| D3240 |
|
1,134 |
385 |
$107K |
| D0350 |
|
8,542 |
3,726 |
$84K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
319 |
105 |
$71K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,248 |
557 |
$68K |
| D0274 |
Bitewings - four radiographic images |
2,222 |
2,212 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
512 |
371 |
$40K |
| D0603 |
|
2,569 |
2,546 |
$38K |
| D0145 |
Oral evaluation for a patient under three years of age |
527 |
527 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,985 |
2,965 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
587 |
586 |
$27K |
| D2330 |
|
337 |
187 |
$25K |
| D9430 |
|
751 |
720 |
$24K |
| D9222 |
|
106 |
103 |
$12K |
| D0602 |
|
652 |
638 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
770 |
706 |
$9K |
| D9610 |
|
144 |
72 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
138 |
$5K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$3K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$79.00 |