| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,767 |
6,271 |
$344K |
| D1206 |
Topical application of fluoride varnish |
6,960 |
6,455 |
$329K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,445 |
291 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,187 |
2,889 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,673 |
2,521 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
5,224 |
4,796 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,806 |
2,608 |
$51K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
855 |
219 |
$42K |
| D1351 |
Sealant - per tooth |
1,797 |
366 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,832 |
4,920 |
$37K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
263 |
140 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
585 |
277 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
899 |
826 |
$26K |
| D0330 |
Panoramic radiographic image |
499 |
459 |
$16K |
| D0350 |
|
2,920 |
1,745 |
$12K |
| D0274 |
Bitewings - four radiographic images |
565 |
523 |
$12K |
| D9310 |
|
127 |
119 |
$7K |
| D9612 |
|
150 |
140 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
235 |
216 |
$4K |
| D7111 |
|
122 |
41 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
65 |
$4K |
| D0603 |
|
1,004 |
888 |
$4K |
| D9222 |
|
62 |
62 |
$3K |
| D0999 |
Unspecified diagnostic procedure, by report |
102 |
102 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
88 |
88 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
44 |
44 |
$890.87 |
| D0240 |
|
51 |
48 |
$664.58 |
| D0602 |
|
58 |
55 |
$229.75 |