| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
21,370 |
21,368 |
$737K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,768 |
3,842 |
$464K |
| D1351 |
Sealant - per tooth |
8,798 |
3,434 |
$374K |
| D0120 |
Periodic oral evaluation - established patient |
16,101 |
16,099 |
$373K |
| D0274 |
Bitewings - four radiographic images |
16,993 |
16,991 |
$370K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,484 |
1,758 |
$238K |
| D1206 |
Topical application of fluoride varnish |
8,629 |
8,627 |
$227K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,224 |
3,041 |
$183K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,830 |
14,830 |
$176K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
7,192 |
7,191 |
$164K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,681 |
2,563 |
$159K |
| D1110 |
Prophylaxis - adult |
2,626 |
2,626 |
$110K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,552 |
1,228 |
$109K |
| D0220 |
Intraoral - periapical first radiographic image |
7,396 |
7,372 |
$75K |
| D0330 |
Panoramic radiographic image |
1,997 |
1,997 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
2,460 |
2,458 |
$49K |
| D1510 |
|
472 |
430 |
$47K |
| D0272 |
Bitewings - two radiographic images |
3,807 |
3,804 |
$42K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,517 |
1,517 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,121 |
3,035 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
2,579 |
2,542 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,589 |
5,569 |
$28K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
27 |
27 |
$6K |
| D7111 |
|
248 |
162 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
56 |
$4K |
| D2330 |
|
100 |
85 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
28 |
28 |
$3K |
| D9222 |
|
27 |
27 |
$1K |
| D2332 |
|
13 |
12 |
$879.46 |
| D1354 |
|
34 |
13 |
$714.90 |
| D0602 |
|
546 |
545 |
$533.00 |
| D9996 |
|
42 |
41 |
$455.99 |
| D0603 |
|
384 |
384 |
$369.00 |
| D0601 |
|
342 |
342 |
$341.00 |
| D9987 |
|
229 |
223 |
$0.00 |