| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
17,218 |
15,685 |
$842K |
| D1206 |
Topical application of fluoride varnish |
18,165 |
16,502 |
$815K |
| D1351 |
Sealant - per tooth |
16,515 |
3,814 |
$273K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
4,161 |
2,271 |
$266K |
| D0120 |
Periodic oral evaluation - established patient |
9,416 |
8,467 |
$259K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
9,435 |
8,379 |
$245K |
| D0272 |
Bitewings - two radiographic images |
8,774 |
7,826 |
$151K |
| D0220 |
Intraoral - periapical first radiographic image |
11,805 |
10,483 |
$146K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,958 |
15,958 |
$128K |
| D0274 |
Bitewings - four radiographic images |
6,061 |
5,488 |
$122K |
| D1354 |
|
11,300 |
2,115 |
$103K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,042 |
5,837 |
$98K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,699 |
282 |
$93K |
| D0330 |
Panoramic radiographic image |
2,365 |
2,276 |
$90K |
| D2140 |
|
1,736 |
1,154 |
$82K |
| D1353 |
|
3,713 |
1,110 |
$50K |
| D1110 |
Prophylaxis - adult |
1,091 |
1,004 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,595 |
4,151 |
$39K |
| D4346 |
|
319 |
258 |
$37K |
| D2160 |
|
306 |
200 |
$28K |
| D2929 |
|
396 |
67 |
$28K |
| D0603 |
|
6,801 |
6,159 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
1,066 |
779 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
440 |
265 |
$19K |
| D0999 |
Unspecified diagnostic procedure, by report |
560 |
560 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
445 |
243 |
$16K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
421 |
146 |
$15K |
| D9999 |
Unspecified adjunctive procedure, by report |
605 |
605 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
209 |
61 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
124 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
103 |
$6K |
| D9222 |
|
305 |
146 |
$5K |
| D9420 |
|
162 |
75 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
100 |
100 |
$2K |
| D9310 |
|
22 |
16 |
$922.50 |
| D0170 |
|
43 |
43 |
$774.48 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$635.50 |
| D0350 |
|
590 |
336 |
$574.00 |
| D9630 |
|
508 |
373 |
$367.81 |
| D3120 |
|
44 |
13 |
$328.00 |
| D1999 |
|
922 |
884 |
$285.00 |
| D9993 |
|
438 |
413 |
$194.75 |
| D9215 |
|
163 |
125 |
$141.45 |
| D4921 |
|
52 |
14 |
$0.00 |