| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,937 |
9,877 |
$478K |
| D0120 |
Periodic oral evaluation - established patient |
5,750 |
5,722 |
$401K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
676 |
427 |
$394K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,297 |
548 |
$268K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,489 |
3,456 |
$229K |
| D1310 |
|
4,883 |
4,854 |
$219K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,153 |
502 |
$210K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,917 |
9,856 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,451 |
1,319 |
$161K |
| D1351 |
Sealant - per tooth |
3,960 |
1,098 |
$141K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,553 |
3,066 |
$141K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,502 |
9,369 |
$122K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,057 |
1,081 |
$116K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,936 |
1,018 |
$103K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,131 |
1,124 |
$77K |
| D0603 |
|
4,472 |
4,443 |
$66K |
| D0272 |
Bitewings - two radiographic images |
5,394 |
5,339 |
$62K |
| D9222 |
|
431 |
427 |
$53K |
| D9610 |
|
545 |
427 |
$36K |
| D9993 |
|
569 |
568 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,955 |
2,897 |
$35K |
| D0350 |
|
3,564 |
1,320 |
$33K |
| D9430 |
|
900 |
862 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
717 |
716 |
$25K |
| D0330 |
Panoramic radiographic image |
704 |
703 |
$21K |
| D0274 |
Bitewings - four radiographic images |
956 |
954 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
100 |
46 |
$7K |
| D2330 |
|
58 |
28 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
26 |
$2K |
| D2140 |
|
39 |
15 |
$2K |
| D2331 |
|
20 |
12 |
$2K |
| D7111 |
|
23 |
15 |
$1K |
| D0602 |
|
55 |
55 |
$780.00 |
| D0270 |
|
14 |
14 |
$65.00 |
| D1354 |
|
43 |
13 |
$0.00 |