| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
19,572 |
19,479 |
$876K |
| D0120 |
Periodic oral evaluation - established patient |
10,919 |
10,858 |
$727K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,418 |
3,580 |
$415K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,519 |
1,484 |
$411K |
| D1310 |
|
8,857 |
8,825 |
$398K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,319 |
5,298 |
$352K |
| D1208 |
Topical application of fluoride, excluding varnish |
17,952 |
17,866 |
$325K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,874 |
6,601 |
$271K |
| D0230 |
Intraoral - periapical each additional radiographic image |
66,157 |
17,660 |
$269K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,843 |
2,569 |
$251K |
| D1351 |
Sealant - per tooth |
7,893 |
2,626 |
$243K |
| D9993 |
|
2,097 |
2,097 |
$135K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,290 |
1,365 |
$127K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
200 |
183 |
$127K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,398 |
1,394 |
$96K |
| D0603 |
|
6,469 |
6,442 |
$95K |
| D0350 |
|
8,212 |
4,588 |
$85K |
| D0274 |
Bitewings - four radiographic images |
4,191 |
4,159 |
$85K |
| D0272 |
Bitewings - two radiographic images |
6,958 |
6,918 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
5,302 |
5,226 |
$60K |
| D3240 |
|
510 |
322 |
$48K |
| D9222 |
|
183 |
183 |
$22K |
| D9430 |
|
704 |
677 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
234 |
184 |
$18K |
| D9610 |
|
183 |
183 |
$15K |
| D0601 |
|
673 |
671 |
$9K |
| D2330 |
|
62 |
28 |
$5K |
| D1354 |
|
395 |
111 |
$3K |
| D0602 |
|
210 |
207 |
$3K |
| D1510 |
|
13 |
12 |
$3K |
| D2331 |
|
29 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$2K |
| D1206 |
Topical application of fluoride varnish |
186 |
186 |
$1K |
| D0270 |
|
136 |
132 |
$680.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D1999 |
|
31 |
31 |
$138.00 |