| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
21,239 |
21,080 |
$881K |
| D0120 |
Periodic oral evaluation - established patient |
12,701 |
12,630 |
$821K |
| D1310 |
|
12,357 |
12,313 |
$554K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,831 |
1,660 |
$552K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,756 |
840 |
$551K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,373 |
5,361 |
$361K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,915 |
1,975 |
$324K |
| D1208 |
Topical application of fluoride, excluding varnish |
17,926 |
17,844 |
$294K |
| D0230 |
Intraoral - periapical each additional radiographic image |
66,019 |
16,370 |
$287K |
| D9993 |
|
4,567 |
4,564 |
$278K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,784 |
2,772 |
$187K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,795 |
906 |
$172K |
| D0603 |
|
10,125 |
10,091 |
$147K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,243 |
1,100 |
$143K |
| D1351 |
Sealant - per tooth |
4,082 |
1,378 |
$133K |
| D0272 |
Bitewings - two radiographic images |
9,641 |
9,574 |
$109K |
| D9222 |
|
813 |
811 |
$99K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,305 |
2,181 |
$91K |
| D9610 |
|
935 |
853 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,054 |
636 |
$66K |
| D0220 |
Intraoral - periapical first radiographic image |
5,039 |
4,977 |
$58K |
| D9430 |
|
1,640 |
1,597 |
$52K |
| D2140 |
|
720 |
465 |
$37K |
| D0350 |
|
2,588 |
1,600 |
$27K |
| D2332 |
|
333 |
198 |
$26K |
| D2330 |
|
328 |
199 |
$24K |
| D1510 |
|
118 |
83 |
$23K |
| D0602 |
|
1,431 |
1,422 |
$21K |
| D0274 |
Bitewings - four radiographic images |
783 |
775 |
$16K |
| D1354 |
|
1,308 |
524 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
168 |
$11K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$4K |
| D0601 |
|
132 |
131 |
$2K |
| D9248 |
|
24 |
24 |
$840.00 |
| D1352 |
|
18 |
14 |
$577.50 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$321.50 |
| D9920 |
|
44 |
40 |
$140.00 |
| D9970 |
|
19 |
12 |
$0.00 |
| D1330 |
|
6,532 |
6,529 |
$0.00 |
| D3120 |
|
14 |
12 |
$0.00 |