| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,567 |
15,567 |
$546K |
| D0120 |
Periodic oral evaluation - established patient |
14,588 |
14,588 |
$347K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,659 |
1,277 |
$340K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,266 |
1,977 |
$338K |
| D1206 |
Topical application of fluoride varnish |
20,073 |
20,073 |
$331K |
| D1110 |
Prophylaxis - adult |
5,527 |
5,527 |
$280K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,668 |
1,510 |
$241K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,654 |
6,377 |
$217K |
| D0274 |
Bitewings - four radiographic images |
6,835 |
6,835 |
$190K |
| D1351 |
Sealant - per tooth |
6,140 |
1,740 |
$184K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,575 |
900 |
$173K |
| D0330 |
Panoramic radiographic image |
3,406 |
3,406 |
$167K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,917 |
3,917 |
$161K |
| D0272 |
Bitewings - two radiographic images |
8,010 |
8,010 |
$152K |
| D0220 |
Intraoral - periapical first radiographic image |
7,209 |
7,183 |
$92K |
| D9248 |
|
922 |
907 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,962 |
5,773 |
$62K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
684 |
388 |
$57K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,223 |
1,223 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
1,301 |
1,293 |
$50K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
277 |
78 |
$26K |
| D0240 |
|
1,202 |
649 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,107 |
1,107 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
64 |
$10K |
| D9222 |
|
64 |
64 |
$6K |
| D9920 |
|
12 |
12 |
$620.40 |