| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
3,403 |
3,145 |
$141K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,158 |
503 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,032 |
1,084 |
$125K |
| D1120 |
Prophylaxis - child |
4,520 |
4,490 |
$97K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,217 |
696 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,326 |
629 |
$67K |
| D1206 |
Topical application of fluoride varnish |
4,992 |
4,959 |
$67K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,485 |
1,906 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,850 |
1,735 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
3,018 |
3,002 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,203 |
1,198 |
$30K |
| D1351 |
Sealant - per tooth |
1,277 |
499 |
$28K |
| D9310 |
|
363 |
362 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,227 |
1,184 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,558 |
2,489 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
229 |
98 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,012 |
998 |
$13K |
| D1110 |
Prophylaxis - adult |
258 |
256 |
$6K |
| D2330 |
|
71 |
27 |
$6K |
| D0240 |
|
566 |
344 |
$6K |
| D3120 |
|
444 |
241 |
$5K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
70 |
12 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
209 |
$4K |
| D0330 |
Panoramic radiographic image |
204 |
204 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
119 |
119 |
$2K |
| D1354 |
|
81 |
32 |
$972.00 |
| D9222 |
|
12 |
12 |
$768.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$430.56 |
| D1510 |
|
17 |
12 |
$0.00 |