| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
21,593 |
21,593 |
$759K |
| D0120 |
Periodic oral evaluation - established patient |
19,818 |
19,818 |
$472K |
| D1206 |
Topical application of fluoride varnish |
25,350 |
25,350 |
$420K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,570 |
2,373 |
$378K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,944 |
1,192 |
$256K |
| D0272 |
Bitewings - two radiographic images |
11,463 |
11,463 |
$220K |
| D1110 |
Prophylaxis - adult |
4,285 |
4,285 |
$217K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,053 |
5,963 |
$196K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,757 |
1,014 |
$192K |
| D1351 |
Sealant - per tooth |
5,817 |
1,702 |
$177K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,959 |
3,959 |
$163K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,632 |
1,229 |
$149K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,547 |
2,547 |
$123K |
| D0330 |
Panoramic radiographic image |
1,987 |
1,987 |
$103K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
843 |
535 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
4,513 |
4,489 |
$58K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
265 |
123 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
458 |
457 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,537 |
648 |
$17K |
| D9222 |
|
123 |
123 |
$14K |
| D9310 |
|
72 |
72 |
$5K |