| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
14,700 |
14,631 |
$695K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,078 |
1,226 |
$609K |
| D0120 |
Periodic oral evaluation - established patient |
9,258 |
9,214 |
$601K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
3,364 |
681 |
$535K |
| D1310 |
|
10,684 |
10,633 |
$487K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,358 |
1,138 |
$433K |
| D1206 |
Topical application of fluoride varnish |
14,156 |
14,089 |
$312K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,509 |
3,507 |
$240K |
| D0230 |
Intraoral - periapical each additional radiographic image |
43,925 |
9,988 |
$190K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,537 |
2,527 |
$172K |
| D9993 |
|
2,647 |
2,645 |
$169K |
| D0603 |
|
10,448 |
10,396 |
$155K |
| D0220 |
Intraoral - periapical first radiographic image |
10,540 |
10,266 |
$126K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,050 |
1,043 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,373 |
730 |
$92K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,173 |
2,086 |
$87K |
| D9222 |
|
682 |
681 |
$84K |
| D1351 |
Sealant - per tooth |
1,847 |
570 |
$60K |
| D9610 |
|
1,885 |
667 |
$56K |
| D9430 |
|
1,409 |
1,387 |
$45K |
| D0350 |
|
1,777 |
843 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
153 |
$12K |
| D0272 |
Bitewings - two radiographic images |
522 |
521 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
377 |
376 |
$5K |
| D0601 |
|
94 |
94 |
$1K |
| D1354 |
|
73 |
16 |
$560.00 |