| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,526 |
5,455 |
$286K |
| D0120 |
Periodic oral evaluation - established patient |
3,665 |
3,612 |
$259K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,567 |
445 |
$188K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,187 |
922 |
$147K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,711 |
1,694 |
$115K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,516 |
5,446 |
$99K |
| D1351 |
Sealant - per tooth |
2,596 |
662 |
$98K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,586 |
4,797 |
$98K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
882 |
314 |
$88K |
| D1310 |
|
1,811 |
1,788 |
$82K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,120 |
1,050 |
$45K |
| D0272 |
Bitewings - two radiographic images |
3,712 |
3,657 |
$44K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
234 |
64 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
513 |
277 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
288 |
181 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
391 |
177 |
$22K |
| D0603 |
|
1,136 |
1,117 |
$17K |
| D0274 |
Bitewings - four radiographic images |
648 |
639 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
133 |
133 |
$9K |
| D9222 |
|
63 |
63 |
$8K |
| D0601 |
|
500 |
499 |
$7K |
| D2330 |
|
77 |
46 |
$6K |
| D9610 |
|
104 |
52 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
359 |
357 |
$4K |
| D9430 |
|
84 |
79 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$2K |
| D9993 |
|
15 |
15 |
$910.00 |
| D0330 |
Panoramic radiographic image |
21 |
21 |
$630.00 |