| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,798 |
15,712 |
$772K |
| D0120 |
Periodic oral evaluation - established patient |
9,738 |
9,688 |
$642K |
| D1310 |
|
9,489 |
9,433 |
$427K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,597 |
15,508 |
$331K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,815 |
1,185 |
$331K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,710 |
3,687 |
$248K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,594 |
1,700 |
$238K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,412 |
1,011 |
$234K |
| D1351 |
Sealant - per tooth |
4,760 |
1,416 |
$171K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,042 |
1,753 |
$170K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,719 |
3,545 |
$149K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33,221 |
11,076 |
$141K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,001 |
1,987 |
$138K |
| D0603 |
|
9,137 |
9,082 |
$134K |
| D0272 |
Bitewings - two radiographic images |
7,994 |
7,959 |
$93K |
| D9993 |
|
793 |
792 |
$50K |
| D0350 |
|
3,752 |
1,918 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
650 |
445 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,754 |
2,699 |
$33K |
| D9430 |
|
974 |
943 |
$30K |
| D1352 |
|
618 |
178 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
166 |
$19K |
| D0274 |
Bitewings - four radiographic images |
890 |
884 |
$19K |
| D0340 |
|
313 |
313 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
322 |
322 |
$11K |
| D0330 |
Panoramic radiographic image |
317 |
316 |
$9K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
33 |
12 |
$8K |
| D1354 |
|
346 |
72 |
$3K |
| D2330 |
|
37 |
13 |
$3K |
| D9222 |
|
12 |
12 |
$1K |
| D9610 |
|
26 |
12 |
$966.00 |
| D0601 |
|
54 |
54 |
$780.00 |
| D0602 |
|
15 |
15 |
$225.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$140.00 |
| D0270 |
|
12 |
12 |
$60.00 |