| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,157 |
4,121 |
$208K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,055 |
266 |
$125K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,632 |
1,601 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
1,544 |
1,542 |
$104K |
| D1310 |
|
2,164 |
2,147 |
$97K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,092 |
4,054 |
$86K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
597 |
198 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
780 |
430 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,167 |
3,042 |
$49K |
| D0350 |
|
5,420 |
1,905 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
937 |
838 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
440 |
440 |
$29K |
| D0603 |
|
1,807 |
1,791 |
$26K |
| D1351 |
Sealant - per tooth |
515 |
152 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
297 |
215 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,000 |
985 |
$12K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
44 |
24 |
$11K |
| D0274 |
Bitewings - four radiographic images |
769 |
759 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
174 |
83 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
701 |
690 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
85 |
$4K |
| D9430 |
|
93 |
92 |
$3K |
| D9222 |
|
24 |
24 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$3K |
| D0602 |
|
43 |
43 |
$630.00 |