| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,849 |
11,849 |
$488K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,843 |
914 |
$371K |
| D0120 |
Periodic oral evaluation - established patient |
10,537 |
10,536 |
$287K |
| D1351 |
Sealant - per tooth |
5,159 |
1,861 |
$253K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,015 |
592 |
$211K |
| D1206 |
Topical application of fluoride varnish |
6,060 |
6,060 |
$175K |
| D0272 |
Bitewings - two radiographic images |
10,061 |
10,059 |
$162K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,559 |
1,189 |
$117K |
| D9310 |
|
1,200 |
1,199 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,940 |
6,940 |
$93K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
238 |
238 |
$83K |
| D2331 |
|
956 |
280 |
$80K |
| D0330 |
Panoramic radiographic image |
2,095 |
2,095 |
$74K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,049 |
691 |
$60K |
| D1110 |
Prophylaxis - adult |
1,081 |
1,081 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,540 |
1,540 |
$44K |
| D0240 |
|
2,376 |
1,418 |
$41K |
| D2335 |
|
281 |
78 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
269 |
242 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,081 |
1,081 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,955 |
1,936 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
397 |
310 |
$18K |
| D9222 |
|
237 |
237 |
$17K |
| D2394 |
|
58 |
33 |
$7K |
| D1354 |
|
183 |
92 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
90 |
90 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
150 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
742 |
686 |
$750.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$159.60 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$46.70 |
| D0603 |
|
139 |
139 |
$0.00 |
| D1330 |
|
144 |
144 |
$0.00 |