| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,362 |
1,361 |
$67K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
558 |
144 |
$66K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
595 |
160 |
$58K |
| D1351 |
Sealant - per tooth |
1,419 |
346 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
805 |
805 |
$52K |
| D1310 |
|
936 |
935 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,362 |
1,359 |
$31K |
| D1510 |
|
118 |
78 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,415 |
1,109 |
$22K |
| D9920 |
|
149 |
147 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
378 |
377 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
265 |
265 |
$16K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
70 |
17 |
$15K |
| D1354 |
|
1,355 |
212 |
$15K |
| D2330 |
|
178 |
61 |
$14K |
| D0603 |
|
937 |
935 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
120 |
$13K |
| D0350 |
|
1,201 |
382 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
220 |
201 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
57 |
$8K |
| D0272 |
Bitewings - two radiographic images |
635 |
634 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
59 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
487 |
$6K |
| D9430 |
|
125 |
124 |
$4K |
| D9222 |
|
17 |
17 |
$2K |
| D9610 |
|
42 |
17 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D1320 |
|
37 |
37 |
$350.00 |