| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,796 |
9,755 |
$500K |
| D0120 |
Periodic oral evaluation - established patient |
5,243 |
5,225 |
$345K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,701 |
1,316 |
$321K |
| D1310 |
|
6,499 |
6,469 |
$295K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,809 |
1,146 |
$277K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,795 |
3,778 |
$254K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,378 |
1,670 |
$224K |
| D1351 |
Sealant - per tooth |
4,898 |
1,534 |
$185K |
| D0230 |
Intraoral - periapical each additional radiographic image |
43,263 |
8,716 |
$174K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,733 |
1,327 |
$156K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,129 |
6,093 |
$140K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,871 |
1,864 |
$125K |
| D0603 |
|
6,479 |
6,449 |
$96K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,202 |
2,014 |
$88K |
| D1206 |
Topical application of fluoride varnish |
3,413 |
3,410 |
$77K |
| D1510 |
|
368 |
302 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,276 |
708 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
4,847 |
4,612 |
$57K |
| D9430 |
|
1,651 |
1,578 |
$52K |
| D0272 |
Bitewings - two radiographic images |
4,128 |
4,102 |
$48K |
| D0350 |
|
4,172 |
1,900 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
425 |
286 |
$34K |
| D9248 |
|
783 |
743 |
$27K |
| D2332 |
|
335 |
190 |
$27K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
53 |
26 |
$22K |
| D0274 |
Bitewings - four radiographic images |
964 |
964 |
$20K |
| D1354 |
|
1,394 |
273 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
171 |
171 |
$8K |
| D2330 |
|
48 |
25 |
$4K |
| D2335 |
|
27 |
12 |
$3K |
| D9222 |
|
26 |
26 |
$3K |
| D9610 |
|
29 |
26 |
$2K |
| D0270 |
|
39 |
38 |
$195.00 |